UNDERSTANDING NUTRITION

A Primer on Programs and Policies in California

Diane F. Reed, M.P.H. Kate Karpilow, Ph.D.

CALIFORNIA CENTER FOR RESEARCH ON WOMEN & FAMILIES

a program of the Public Health Institute

CALIFORNIA CENTER FOR RESEARCH ON WOMEN & FAMILIES

August 2004 Dear Policymakers, Advocates, Service Providers, and Other Leaders: Posted at the California border in a recent Non Sequitur cartoon is a Stop for Inspection sign with this warning: No fruits, vegetables, or excess body fat beyond this point. Thats the myth about California that we are all trim, tan, and athletic. We even have a body-building Governor. The truth is that 57% of all California adults are overweight or obese, not strikingly different from the national average of 59%. And of great concern to public health officials and parents across the state, one-quarter of all California teens and one-third of our children ages 9 to 11 are overweight. We have become a nation of super-sized bodies. The consequences of being overweight and obese go far beyond appearances and larger pant sizes. Nationally, poor diet and lack of activity will soon outstrip cigarette smoking as the top cause of preventable deaths. In California, obesity is estimated to prematurely claim over 33,000 lives each year. Researchers estimating costs attributable to obesity, overweight and physical inactivity predict that over $28 billion will be spent in the state in 2005 for medical care, lost employee productivity, and workers' compensation. Paradoxically, while overweight and obesity have reached what public health officials call epidemic proportions, many California families and children still go hungry. Just over one-fifth of all California women, typically those who are younger, poorer, and less educated, do not always have dependable meals for themselves and their children. A recent federal study found that 806,000 adults and 447,000 children in California reported not having enough food and being hungry. How can the nations most abundant agricultural state not reliably feed all of its families and children? Understanding Nutrition: A Primer on Programs and Policies in California aims to orient policymakers and others, particularly those new to their positions, to the federal and state agencies, programs, and laws established to address nutrition-related issues, including overweight and obesity, hunger, diet, and physical activity. By identifying existing resources, as well as current policy issues under discussion, we hope the Primer advances thoughtful discussion and public policy. Diane F. Reed, the primary author of the Primer, has our considerable thanks for her extensive research and writing. We also appreciate the ongoing contributions of our expert advisory committee, most notably Ken Hecht, Executive Director, California Food Policy Advocates; Laurie True, Executive Director, California Women, Infants and Childrens Program Association; Susan B. Foerster, Chief, Cancer Prevention and Nutrition Section, California Department of Health Services; Maria Boyle, Associate, Samuels and Associates; Arnell Hinkle, Executive Director, California Adolescent Nutrition and Fitness Program; and Carolyn Brown, Special Assistant to the Director, Nutrition Services Division, California Department of Education. We also thank the California Nutrition Network for Healthy, Active Families (funded by the U.S. Department of Agriculture Food Stamp Program) for its support of this Primer. California can only be a vital and productive state if Californians themselves are healthy and not hungry. We hope that Understanding Nutrition assists policymakers and other leaders to craft nutrition-related policy and programs that support the health of all Californians. Sincerely,

Kate Karpilow, Ph.D. Executive Director

California Center for Research on Women and Families 1654 Solano Avenue, Suite D Berkeley, CA 94707-2114 Tel: (510) 559-2696 Fax: (510) 559-2699 www.ccrwf.org

CCRWF is a program of the Public Health Institute

A PRIMER
Introduction

UNDERSTANDING NUTRITION: ON PROGRAMS AND POLICIES IN CALIFORNIA

Table Of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Statistical Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . .2 Hunger and Food Insecurity . . . . . . . . . . . . . . . . . . . . . .5 Diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Consequences of Poor Nutrition, Hunger, and Physical Inactivity . . . . . . . . . . . . . . . . . . . . . . .12 The Role of Government . . . . . . . . . . . . . . . . . . . . . . . .13 The Federal System . . . . . . . . . . . . . . . . . . . . . . . . . . .13 U.S. Department of Agriculture . . . . . . . . . . . . . . .13 Department of Health and Human Services . . . . . .15 Department of Defense . . . . . . . . . . . . . . . . . . . . .16 Department of Education . . . . . . . . . . . . . . . . . . . .16 Key Federal Legislation . . . . . . . . . . . . . . . . . . . . . .17 The State System . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Department of Education . . . . . . . . . . . . . . . . . . . .21 Department of Social Services . . . . . . . . . . . . . . . .21 Department of Health Services . . . . . . . . . . . . . . . .21 Department of Aging . . . . . . . . . . . . . . . . . . . . . . .22 University of California Cooperative Extension . . . .22 Department of Food and Agriculture . . . . . . . . . . .22 Key State Legislation . . . . . . . . . . . . . . . . . . . . . . .23 Public Nutrition and Food Assistance Programs in California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Food Stamp Program . . . . . . . . . . . . . . . . . . . . . . . . . .24 WIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Child Nutrition Programs . . . . . . . . . . . . . . . . . . . . . .28 Older Adult Programs . . . . . . . . . . . . . . . . . . . . . . . . .32 Food Distribution Programs . . . . . . . . . . . . . . . . . . . . .33 Community Food Security . . . . . . . . . . . . . . . . . . . . . . .36 What is CFS? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Key Policy Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 Combating Obesity and Promoting Healthy Eating . . .37 Menu and Product Labeling . . . . . . . . . . . . . . . . . .37 Marketing Junk Food . . . . . . . . . . . . . . . . . . . . . . .38 School Environment . . . . . . . . . . . . . . . . . . . . . . . .39 Nutrition Education at School . . . . . . . . . . . . . . . . .40 Physical Education . . . . . . . . . . . . . . . . . . . . . . . . .41 Worksite Health Promotion . . . . . . . . . . . . . . . . . .41 Community Design and Transportation Planning . .42 Effective Governance . . . . . . . . . . . . . . . . . . . . . . . . . .43 Underutilized Federal Food Programs . . . . . . . . . .43 Untapped Federal Resources . . . . . . . . . . . . . . . . . .45 Program Coordination . . . . . . . . . . . . . . . . . . . . . .45 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

Californians of all ages face a health crisis of unparalleled proportions. Despite numerous food assistance programs, about 5 million predominantly low-income children and adults statewide are hungry or live on the edge of hunger. At the same time, due to numerous individual, community, and economic factors, inactivity and poor diets contribute to overweight and obesity found in nearly 60% of California adults and 25% of children and adolescents under 18. Paradoxically, obesity and hunger can co-exist in the same families and individuals. And, despite the well-publicized benefits of physical activity in preventing or ameliorating disease, about 55% of California adults engage in little or no physical activity, and only 25% of children and adolescents meet minimum physical fitness standards. Understanding Nutrition: A Primer on Programs and Policies in California offers a statistical profile of the weight, dietary practices, and physical activity of Californians, an overview of the relevant federal and state governmental structures and laws, a description of the programs supporting nutrition and community food security, and a review of key policy issues. Throughout, there is an emphasis on the connections between nutrition, food insecurity, physical activity, obesity, and poverty.

ABOUT THIS PRIMER

Understanding Nutrition: A Primer on Programs and Policies in California is one in a series of primers offered through the California Center for Research on Women and Families (CCRWF) to assist practitioners and policy leaders in advancing their basic knowledge of complex social service systems. This Primer provides a basic orientation of public federal and state nutrition, food assistance, and physical activity programs, particularly those serving low-income Californians.

FOR ADDITIONAL COPIES

Copies of this Primer can be downloaded from the CCRWF website at www.ccrwf.org.

RECOMMENDED CITATION:
Reed, D. F., & Karpilow, K. A. (2004, August). Understanding nutrition: A primer on programs and policies in California. Berkeley, CA: California Center for Research on Women and Families, Public Health Institute. Available on the CCRWF website, www.ccrwf.org.
Public Health Institute, California Center for Research on Women and Families, 2004 (Second Printing, 2005)

STATISTICAL PROFILE
Over the past few decades, the eating habits, weight, and physical activity of Californians have changed considerably. This section summarizes key statistics related to overweight and obesity, hunger and food insecurity, nutrition, and physical activity. The high prevalence of overweight and obesity is associated with a number of factors, including: High consumption of soft drinks and food high in fat and sugar;2 Large portion sizes served in fast food chains, homes, and restaurants;3,4 Availability of fast food, soda, and junk food on school campuses;5,6 Limited access to healthy and affordable foods in low-income communities;7 Aggressive marketing of junk food to children and their families;8 and Inadequate infrastructures for physical activity in schools and communities.9 National studies have documented significant increases in overweight and obesity among Americans since the 1970s. Among U.S. adults ages 20 to 74 years, the prevalence of overweight increased from 47% in 1976-80 to 64% in 1999-2000, and obesity more than doubled from 15% to 31%.10 Between 1971-74 and 1999-2000, the prevalence of overweight children ages 6 to 11 nearly quadrupled from 4% to 15%, and the prevalence of overweight adolescents ages 12 to 19 more than doubled from 6% to 15%.11 Various studies demonstrate that overweight and obesity are pressing public health issues not just nationally, but for California as well.12

Overweight and Obesity

Genetic, metabolic, behavioral, environmental, cultural, and socioeconomic factors combine to determine individual body weight. According to the United States Surgeon General, the prevalence of overweight and obesity has reached epidemic proportions, largely resulting from overconsumption of calories and/or insufficient physical activity.1

Body Mass Index (BMI) in Adults

According to the Centers for Disease Control (CDC) National Center for Chronic Disease Prevention and Health Promotion, overweight refers to increased body weight in relation to height, when compared to some standard of acceptable or desirable weight. Body Mass Index, or BMI, is a relationship between weight and height that is associated with body fat and health risk. Overweight among adults is commonly defined as having a body mass index (BMI) in the range of 25.529.9. Obesity is defined as an excessively high amount of body fat in relation to lean body mass and is commonly defined as a BMI greater than or equal to 30. To calculate BMI, divide weight in pounds by the square of a person's height in inches and multiply the result by 703. This formula can be represented as:

The CDC provides an online BMI calculator which can be accessed at: http://www.cdc.gov/ nccdphp/dnpa/bmi/ bmi-adult-formula.htm
Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. BMI: Body Mass Index Overview. Retrieved March 19, 2004, from http://www.cdc.gov/ nccdphp/dnpa/bmi/index.htm

TABLE 1. PERCENT

OF

OVERWEIGHT AND OBESE ADULTS 18+, 1992 CALIFORNIA AND U.S.

Percent Obese 1992 11.8 12.6 2002 19.2 22.2 2002 37.5 37.0

AND

2002

Percent Overweight 1992 California U.S. 34.1 34.6

Total Percent 1992 45.9 47.2 2002 56.7 59.1

Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention & Health Promotion, Behavioral Risk Factor Surveillance System. Trends data. Retrieved November 26, 2003, from http://apps.nccd.cdc.gov/brfss/Trends/TrendData.asp

ADULTS IN CALIFORNIA
Recent data (2002) show comparable proportions of overweight adults in California (37.5%) and nationally (37%), while obesity among Californians (19.2%) was somewhat lower than among adults nationally (22.2%). Over the last decade,* overweight and obesity increased both in California and the nation (Table 1).13

Between 1992 and 2002, the percentage of California adults who were overweight or obese had increased within every racial/ethnic group, except among African Americans (Figure 1). In 1992, the highest percentage of overweight and obese Californians was among African Americans (67%). By 2002, Latinos had the highest percentage of overweight and obesity (68%), closely followed by African Americans (65%).14

FIGURE 1. PERCENT

OF

BY

OVERWEIGHT AND OBESE CALIFORNIA ADULTS* RACE/ETHNICITY, 1992-2002

*Age adjusted to the 1990 California population. Includes both overweight and obesity. Source: Personal communication re: California Behavioral Risk Factor Survey, 19842002, March 3, 2004, S. Sugerman, Research Scientist, Survey Research Group, California Department of Health Services, Survey Research Group.

* Data from a state study (Figure 1), the California Behavioral Risk Factor Survey (CBRFS), show a slightly lower level of overweight and obesity among California adults than found in the national CDC study (Table 1). CBRFS data indicate that obesity among California adults rose from 46% in 1992 to 54.4% in 2002, with 62% of men overweight or obese, compared to 46.7% of women. Personal communication re: California Behavioral Risk Factor Survey, 19842002, March 3, 2004, S. Sugerman, Research Scientist, Survey Research Group, California Department of Health Services.
3

CHILDREN AND TEENS IN CALIFORNIA

The Body Mass Index (BMI) is calculated for children and teens using weight, height, age, and gender. Researchers generally do not use the term obese when referring to children and adolescents, but describe them as at risk of overweight or overweight. Adolescents with a BMI above the 85th but below the 95th percentile are at risk of overweight. Those in the 95th percentile and over are considered overweight.* Children. In 1999, one-third of California children aged 9 to 11 years old were at risk of overweight or overweight.15 5th, 7th, and 9th Graders. In 2001, an average of 26.5% of all 5th, 7th, and 9th grade California students

were at risk of overweight or were overweight,16 based on an analysis of annual mandatory statewide physical fitness testing results.17 Teens. California adolescents ages 12 to 17 who were at risk of overweight or were overweight rose from 21% in 1998 to 25% in 2000. While the proportion of overweight boys was highest (26% in 2000), the largest increase was found with girls, rising from 17% in 1998 to 22% in 2000.18 Ethnic Differences. In 2000, 34% of Latino, 29% of African American, 17% of white, and 21% of Asian/other teens were at risk for overweight or overweight.19

Background on Obesity
Fifty years ago, the American Heart Association identified obesity as a cardiovascular risk factor that could be changed by diet and exercise. However, early recommendations and guidelines issued by federal agencies and private organizations proved overly simplistic and of little help to people struggling with overweight. As late as 1977, the Senate Select Committee on Nutrition and Human Needs issued Dietary Goals for the United States which recommended: To avoid overweight, consume only as much energy [calories] as is expended; if overweight, decrease energy intake and increase energy expenditure.a Early assessments of the causes of overweight and obesity rarely addressed cultural and environmental factors, such as aggressive marketing of high fat and sugar products with low nutrition value, lack of nutrition labeling, larger portions served in restaurants, or the availability of safe public spaces for physical activity. Nor were comprehensive solutions proposed, such as mass media educational campaigns and model school programs. In 1980, preventing obesity in individuals and population groups was formally established as a national public health policy goal in the U.S. Department of Health and Human Services publication Promoting Health/Preventing Disease. Since then, subsequent federal health goals published in Healthy People 2000 and Healthy People 2010 b emphasize reducing overweight and obesity and increasing sound nutrition practices and regular physical activity. Despite a national obsession with thinness and increased attention focused on prevention, activity levels of Americans have changed very little, and obesity has doubled over the last 25 years. Some researchers call on public health officials to recognize that when it comes to obesity, our societys environment is toxic deeply rooted [in] cultural, social, and economic factors that actively encourage overeating and sedentary behavior and discourage alterations in these patterns.c
a U.S. Senate, Select Committee on Nutrition and Human Needs. (1977). Dietary goals for the U.S. Washington, D.C.: U.S. Government Printing Office.

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2000, November). Healthy People 2010: Understanding and improving health. (2nd ed.). Washington, DC: U.S. Government Printing Office. Available from the Healthy People 2010 website, http://www.healthypeople.gov/
c

Nestle, M., & Jacobson, M.F. (2000, January/February). Halting the obesity epidemic: A public health policy approach. Public Health Reports, 115, 1224.

* Additional information on the BMI for children and teens can be found on the Centers for Disease Control website, www.cdc.gov/nccdphp/dnpa/bmi/. A BMI calculator can also be accessed on the Keep Kids Healthy website, http://www.keepkidshealthy.com/welcome/bmicalculator.html.
4

Hunger and Food Insecurity

Food insecurity is an economic and social indicator of household well-being. Households that are food insecure are defined as having limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways.20* A household that reports having hunger has one or more household members that has experienced hunger at some time in the past year due to lack of financial resources. Nationally, an estimated 33 million21,22Americans (including 14 to 16 million children) report being hungry or living on the edge of hunger. For California, where 33.8 million23 people live in the nation's richest agricultural state, the Center on Hunger and Poverty averaged 1998-2000 U.S. Census Bureau survey data** to estimate food insecurity and hunger.24 During that time period: Some 3 million adults and 2 million children experienced food insecurity; and

Among them, 806,000 adults and 447,000 children reported not having enough food and being hungry. Other studies shed light on specific populations statewide: Lower-Income. More than 1 in 4 of all adults with incomes less than 200% of the Federal Poverty Level (or 2.24 million) are estimated to be food insecure or food insecure and hungry.25 Women. Some 22% of women in California are food insecure. Those most affected are younger (under 34), less educated (lacking a high school diploma), and women of color. Higher rates of food insecurity are found among Latinas (48%) and African American women (24%) than among white (14%) or Asian/other (17%) women.26 Teens. Eleven percent of Latino teens in California reported hunger, compared to 10% of African American and 4% of white teens. Thirteen percent of Asian/other teens reported hunger.27

Overweight, Obesity, and Hunger

Paradoxically, overweight and obesity can co-exist with hunger in the same families and the same individuals.a The highest rates of obesity are found among those with the highest poverty rates and the least education.b Moreover, overweight and obesity have replaced malnutrition as the most common nutrition problem among low-income populations.c Low-income families use a variety of coping strategies to stretch their food money as far as possible, and some of these strategies contribute to obesity. Families that lack resources to buy fresh fruits and vegetables, lean meats, and low-fat dairy products often purchase low-cost, non-nutritious foods that are filling (e.g., snacks, soft drinks, and fast foods that are high calorie, high fat, and high sugar) to keep their children from being hungry.d Low-income, food-insecure mothers often restrict their own food intake during periods of food insufficiency to protect their children from hunger. These mothers then sometimes eat more than is necessary when food is available, contributing to obesity among poor women.e
a

Townsend, M. S., et al. (2001). Food insecurity is positively related to overweight in women. Journal of Nutrition, 131, 17381745.

b Drewnowski, A., & Specter, S. E. (2004). Poverty and obesity: The role of energy density and energy costs. American Journal of Clinical Nutrition. 79, 616. c d

Crawford, P. B., et al. (2004, JanuaryMarch). How can Californians be overweight and hungry? California Agriculture, 58(1), 1217.

Brandeis University, Center on Hunger and Poverty. The paradox of hunger and obesity in America. Retrieved July 10, 2003, from http://www. centeronhunger.org/pdf/hungerandobesity.pdf
e

Radimer, K. L., et al. (1992). Understanding hunger and developing indicators to assess it in women and children. Journal of Nutrition Education, 24, 36S45S.

* Food insecure households use a variety of coping strategies to avoid hunger, including eating less varied diets, skipping meals, participating in federal food assistance programs, or getting emergency food from community food pantries. ** The U.S. Census Bureau's annual survey results in households being classified as food secure, food insecure, or food insecure with hunger.

 Immigrants. In 1998, some 79% of Latino and Asian legal immigrants interviewed in hospitals, communitybased clinics, and community centers in California, Texas, and Illinois were hungry or food insecure (a rate seven times higher than in the general population).28 Rural California. Food insecurity is especially high in northern rural counties and the San Joaquin Valley, and the highest prevalence of hunger is found in the Humboldt-Del Norte area and Shasta County.29

California Daily Food Guide and Food Pyramid

The California Daily Food Guide was established in 1990 by the California Department of Health Services to provide the public and professionals with guidelines for adequate nutrients at lower caloric levels to prevent diet-and physical-inactivity-related chronic diseases. The Guide is currently being updated and will be posted at http://www.ca5aday.com. The California Daily Food Guide evolved from the contemporary federal Dietary Guidelines for Americans, but it focused more on chronic disease prevention by emphasizing nutritious food choices at moderate calorie levels for different age and gender groups. Unlike the federal Dietary Guidelines for Americans, the California Daily Food Guide emphasized fruits, vegetables, whole grains, lean animal foods, and legumes as protein sources, and 1% fat (or less) milk within the larger grain, protein, and dairy groups. It recommended that children, adults, and teen girls eat 5 or more servings of fruits and vegetables each day, while 7 or more servings were recommended for teenage boys.* The UCLA Center for Human Nutrition developed a new California Cuisine Pyramid in 1997.a Influenced by the California 5 a Day for Better Health! Campaign, the California pyramid has fruits and vegetables at its base, with grains, breads, high fiber cereals, and starchy vegetables (potatoes and corn) on the second tier the reverse of the USDA Food Guide Pyramid. The California Cuisine pyramid advises a lower level of maximum fat intake (20%) than the USDA pyramid (30%), and recommends plant-derived soy protein as a partial substitute for the meat-derived protein that contributes a considerable amount of total and saturated fat in the diet of many Californians. To enhance taste, the California Pyramid encourages use of spices such as chiles, garlic, peppers, and cilantro, while the USDA Pyramid advocates sparing use of fats, sweets, and oil. The California Pyramid also recommends olives, avocados, and other sources of monounsaturated and omega-3 rich fats to enhance taste and flavor.
* The most recent update of the federal Dietary Guidelines for Americans increased most recommendations for daily fruit and vegetable consumption. The 2000 Dietary Guidelines for Americans now recommend that older children, teen girls, active women, and most men increase their fruit and vegetable intake to 7 servings daily and that teen boys and active men aim for 9 servings a day of fruit and vegetables. Go to http://www.health.gov/ dietaryguidelines/ for more information on the Guidelines. a Heber, D. The California cuisine pyramid. University of California, Los Angeles, Center for Human Nutrition. Retrieved February 5, 2004, from http://www.cellinteractive.com/ucla/center_overview/pyramid.html

THE IMPACT OF POVERTY

The first federal poverty measures, developed in the mid-1960s, defined the Federal Poverty Level as the level below which a familys income could not cover the cost of a nutritionally adequate diet.30 Subsequently, the U.S. Department of Health and Human Services has regularly issued poverty guidelines to determine financial eligibility for certain federal programs. The poverty threshold has been adjusted for inflation over the years, but it has never been updated to reflect the fact that costs for basic needs such as housing, health care, and transportation have risen significantly, taking a larger portion of family income and leaving fewer dollars available for food. Today, millions of lowincome Americans must often choose between paying the rent and eating, making the link between poverty and hunger still strong 40 years later. Nationally, in 2001, food insecurity was over five times as prevalent and hunger was almost seven times as common in U.S. households with annual incomes below 185% of the FPL, compared to households above that level. Food insecurity (with and without hunger) was found in 32.3% of households with incomes below 130% of the poverty line, 40.6% of low-income African American households, 36.8% of low-income Latino households, and 17.4% of low-income elderly living alone.

FPL or Living Wage?

Antipoverty advocates have begun to raise questions about the value of the Federal Poverty Level (FPL) as a reliable standard to determine economic stability as the FPL does not take into account Californias high standard of living or include costs for child care. Some now advocate for a living wage, based on regionalized family expenses for food, housing, transportation, and child care.
* See Making ends meet: How much does it cost to raise a family in California, October 2003, California Budget Project, http://www.cbp.org/ 2003/2003MEMfinal.pdf; or obtain information at the Living Wage Resource Center at http://www.livingwagecampaign.org/.

USDA Food Guide Pyramid

Diet
Compelling evidence exists that eating a high fiber, low fat, low sugar diet rich in fruits, vegetables, and whole grains reduces the risk of many diseases.33 This research-based diet is recommended by the Department of Health and Human Services (DHHS) and the Department of Agriculture (USDA) in their joint publication, Dietary Guidelines for Americans. This publication represents the latest nutrition policies of the federal government. It is updated every 5 years, with the next revision due in 2005. (See http:// www.health.gov/dietaryguidelines/ for more information.) The USDA Food Guide Pyramid graphic was first introduced in 1992 as a part of the Dietary Guidelines for Americans. Unfortunately, the diets of most Americans do not align with advice in the pyramid. About 97% eat too few vegetables, 72% eat too little fruit, and 64% eat too much saturated fat.34 With obesity and other diet-related illnesses on the rise, the USDA food pyramid has been widely criticized as being too simplistic (some oils are healthful and some carbohydrates can cause harm) and having been formulated in reaction to pressure from the cattle, dairy, sugar, and snack food industries. Several other pyramids, including a vegetarian pyramid, a rice- and vegetable-based Asian pyramid, a soul food pyramid, and a Mediterranean diet pyramid emphasizing fish, nuts, and olive oil have been developed to offer improved and culturally relevant food priorities. The first statewide dietary surveys conducted by the California Department of Health Services in 1989 determined that most Californians of all ages were not meeting federal or state dietary guidelines.

For more information on the Food Pyramid, go to: http://www. nalusda.gov/fnic/Fpyr/pyramid.html An updated pyramid is due for release in 2005.

Households with children headed by low-income single mothers were particularly precarious: 45.5% were food insecure, and 13.2% had at least one person, usually the mother, go hungry during the year.31 In California, according to the 2001 California Health Interview Survey (CHIS), among adults whose incomes were less than 200% of the FPL, 28% or 2.24 million were food insecure, including 638,000 who had episodes of hunger that year.32 Other related statistics from that survey include: Single Parents. Some 42% of low-income respondents who were single parents were food insecure, and one out of three of them experienced hunger. Rural Areas. The prevalence of food insecurity was highest among low-income adults in the most agriculturally rich areas of the state, ranging from 33% to 41%. Food Stamp and WIC Participants. Some 51% of food stamp recipients and 40% of women enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) had experienced food insecurity in the previous year.

ADULTS
Dietary trends among California adults from 1989-9935 showed that: Daily consumption of fruits and vegetables has remained well below the recommended 5 servings with the lowest income Californians reporting eating fewer servings of fruits and vegetables than more affluent households whose income exceeds $50,000. On an average day, the percentage of Californians that eat fast food (associated with consuming fewer fruits and vegetables) increased from 15% to 21%.

9 TO 11 YEAR OLDS Proliferation of Fast Food Chains

Nationally, from the late 1970s to the mid-1990s, Americans significantly increased their consumption of foods prepared outside the home, with the percentage of calories attributable to foods prepared outside the home increasing from 18% to 32%.a Foods prepared outside the home typically have more calories and higher total fat and saturated fat than food made at home. During that time period, the number of fast food restaurants more than doubled to an estimated 250,000 nationwide.b Now, on any given day, over one-fifth of Californians eat fast food; and relatively inexpensive fast food chains are often the only source of prepared food in low-income communities. A recent study found 39 fast food restaurants, but only one sit-down eating establishment, within a two-square mile area in South Central Los Angeles.c Although 51% of Californians recently polled opposed limiting the number of fast food restaurants in communities,d 70% of residents surveyed in one South Los Angeles neighborhood saturated with fast food restaurants indicated that they did not want more fast food restaurants in their community, even as new ones were planning to locate in the area.e
Guthrie, J. F., et al. (2002). Role of food prepared away from home in the American diet, 197778 versus 199496: Changes and consequences. Journal of Nutrition Education and Behavior, 34, 140150. U.S. Department of Agriculture, Agricultural Research Service. (2004, January 5). Survey links fast food, poor nutrition among U.S. children. Retrieved March 5, 2004, from http://www.ars.usda.gov/is/pr/ 2004/040105.htm
c b a

A 1999 study of California children ages 9 to 11 years old that surveyed youngsters about their eating habits on a typical school day36 found that only 21% reported meeting the state and national 5 a Day program goal for fruit and vegetable intake. About one-third reported having less than 1 serving of either fruits or vegetables per day. Other key findings include: Fast Food. Some 25% of California children ate fast food on a typical day. Upper-Income Families. Unexpectedly, children from homes in the highest income bracket (over $50,000) averaged fewer servings of fruits and vegetables (2.7), compared to 3.2 servings in middle- and lower-income households. Ethnic Differences. Asian/other children averaged only 2.5 servings of fruits and vegetables, compared to 3 or more servings for each of the other ethnic groups. At School. Some 24% reported that their school cafeteria served brand name fast food (e.g. Taco Bell, McDonalds, Pizza Hut); 8% that their elementary school had vending machines with snacks, chips, cookies, or candy; and 16% that their school vending machines had soda.

TEENS
The first representative survey37of the dietary practices of California teens 12 to 17 years old, conducted in 1998, found a mere 2% of adolescents met the five basic recommendations for eating and physical activity outlined in the 1990 California Daily Food Guide. When the survey was administered again in 2000,38 the following were observed: Vegetables. Some 51% ate no vegetables (even French fries) or salads on the prior day. Fruits and Vegetables. Only 28% of boys and 41% of girls reported eating the minimum amount of fruits and vegetables 7 servings for boys and 5 for girls needed daily for good health. Fast Food. Some 28% ate fast food on a typical day. Junk Food. 73% of teens reported consuming 2 or more servings of pastries, fried foods, chips, desserts, candy, or sodas per day.

Urban and Environmental Policy Institute, Center for Food and Justice. (2002, October). Transportation and food: The importance of access.(A policy brief ). Retrieved March 5, 2004, from http://departments.oxy.edu/uepi/cfj/resources/TransportationAndFood.htm

Field Research Corporation. (2004, March 31). A survey of Californians about the problem of childhood obesity. Retrieved September 7, 2004, from http://www.calendow.org/news/press_releases/2004/03/ ChildObesityCOMPLETEReport3-04.pd Mascarenhas, M. Obesity, diet-related disease, food access, and community-based solutions. [Issue brief]. Retrieved January 2, 2004, from http://departments.oxy.edu/uepi/cfj/resources/Issue%20Brief.htm
e

Regular physical activity substantially reduces the risk of heart attack, diabetes, high blood pressure, stroke, and several types of cancer.

Federal Guidelines for Physical Activity

Healthy People 2010 (HP 2010) is an initiative sponsored by the U.S. Department of Health and Human Services. HP 2010 is a set of objectives to improve the health of Americans over the first decade of the new century. This document has been revised every 10 years since 1980. HP 2010 establishes the following physical activity objectives for adults: Reduce to 20% (from 40%*) the proportion of adults aged 18 and older who engage in no leisure-time physical activity. Increase to 30% (from 15%) the proportion of adults who engage regularly, preferably daily, in moderate intensity** physical activity for at least 30 minutes per day. Increase to 30% (from 23%) the proportion of adults who engage in vigorous intensity*** physical activity, which promotes the development and maintenance of cardio-respiratory fitness on three or more days per week for 20 or more minutes per occasion. HP 2010 establishes the following physical activity objectives for children and youth: Increase to 35% (from 27%) the proportion of adolescents (in grades 9-12) who engage in moderate intensity physical activity for at least 30 minutes on five or more of the previous seven days. Increase to 85% (from 65%) the proportion of adolescents who engage in vigorous intensity physical activity that promotes cardio-respiratory fitness on three or more days per week for 20 or more minutes per occasion. Increase to 50% (from 29%) the proportion of adolescents who participate in daily school physical education.
* The 1997 baselines are in parentheses following each physical activity objective for 2010. **Moderate intensity physical activity is defined as sustained, rhythmic movements and a level of effort equivalent to any activity that burns 3.5 to 7 calories per minute. A person should feel some exertion, but be able to carry on a conversation comfortably during the activity. ***Vigorous intensity physical activity generally means sustained, rhythmic movements and a level of effort equivalent to any activity that burns more than 7 calories per minute. This level of activity should be intense enough to represent a substantial challenge to an individual and result in a significant increase in heart and breathing rate. Source: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2000, November) Healthy People 2010: Understanding and improving health. (2nd ed.). Washington, DC: U.S. Government Printing Office. Available from the Healthy People 2010 website, http://www.healthypeople.gov/

Brief History of Physical Activity

Through the ages, health practitioners have observed that physically inactive people appear to suffer from more health problems than do active people. From 3000 B.C. in China and India, to the ancient Greeks in the 5th century B.C., and into the Middle Ages and Renaissance in Europe, physicians recognized that proper food and exercise were key to good health and overall well-being. In 19th century America, an emerging literature encouraged exercise and becoming better educated about ones body, and European systems of calisthenics and gymnastic exercise were brought to the United States. By the end of the 19th century, exercise and health were discussed frequently by American physicians and educators. By the early 1900s, U.S. physical educators were working on ways to evaluate physical fitness. Observations during World War I that American soldiers were physically unfit shifted the focus of physical education from health-related exercise to performance outcomes. When the United States entered World War II, interest in physical fitness testing and preparedness was again renewed. By 1943, the American Medical Association was reviewing the nature and role of exercise in physical fitness, and a federal advisory council was formed to promote physical fitness in the civilian population. A 1953 study showing that 57% of tested American school children failed to meet minimum standards required for health, compared with 8% of European children, resulted in calls to reform physical education. In the 1960s, conferences, presidential councils, and publications from educational and public health organizations stressed the importance of fitness for children and youth. By the mid-1970s, an emphasis on the health benefits of exercise and physical fitness over performance related to athletic ability reemerged. Over the next two decades, experts began to identify the types of exercise required for specific health outcomes and develop strategies to increase physical activity among sedentary persons.
Source: U.S. Department of Health and Human Services. (1996). Physical activity and health: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. (NTIS No. AD-A329 047/5INT).

Physical Activity
Regular physical activity* substantially reduces the risk of heart attack, diabetes, high blood pressure, stroke, and several types of cancer. It also helps to control weight; contributes to healthy bones, muscles, and joints; reduces falls among older adults; relieves the pain of arthritis; decreases symptoms of depression and anxiety; and is associated with fewer hospitalizations, physician visits, and medications.39

Low levels of physical activity are due, in part, to a number of factors, including: Autos. Increased reliance on the car as a primary form of transportation;42 Walkability/bikeability. Lack of safe pedestrian and biking environments to get to work or school;43 Sprawl. Suburban land use patterns that typically lack green spaces and adequate sidewalks and bike paths;44 Safety. Urban areas that lack safe travel corridors or recreational spaces;45 PE. Physical education classes that are not required or are not interesting for students;46 and Leisure Time. Increased time spent by children watching television, playing video games, and surfing the net.47

ADULTS
Despite the proven benefits of regular physical activity, various surveys show that most Californians do not get nearly enough exercise. According to a 2001 national survey** of California adults age 18 and older:40 Physical Activity. Only 45.8% met the recommended guidelines for moderate or vigorous intensity physical activity, which was about equal to the national adult average of 45.4%. Leisure Activity. Over one-fourth of California adults (26.6%) and American adults (26%) reported no leisure-time physical activity at all.

California Public School Physical Education Requirements

California Education Code requires school districts to offer physical education classes and specifies the minimum number of minutes of physical education that must be provided to students. Elementary grades 1-6 Secondary grades 7-12 Elementary school districts grades 1-8 Minimum of 200 minutes each 10 days Minimum of 400 minutes each 10 days Minimum of 200 minutes each 10 days

TEENS
The 2000 California Teen Eating, Exercise and Nutrition Survey (CalTEENS)41 conducted among California adolescents 12 to 17 years old, found that: Vigorous Exercise. Only 26% reported getting the recommended minimum one hour of vigorous physical activity per day. Physical Activity. Some 9% of girls and 3% of boys reported not having performed a single physical activity in the last week. Ethnic Differences. Latino (12%), African American (7%), and Asian/other (6%) youth had considerably more physical inactivity than their white (3%) counterparts. Leisure Activity. Teens reported spending twice as much time each day (134 minutes) watching television or playing video games as being moderately or vigorously physically active (66 minutes).

The intention of the Education Code is to have daily physical education available in all grade levels. However, since 1978 students can be exempted from physical education for any two years during grades ten through twelve (Education Code Section 51241). Also, under certain circumstances, the California State Board of Education will partially waive some requirements for middle and secondary schools.
Source: California State Board of Education. Physical Education Requirements. (Policy #99-03). Retrieved April 26, 2004, from http://www.cde.ca.gov/be/ms/po/policy99-03-June1999.asp

* Regular physical activity refers to activities that are performed most days of the week, preferably daily. (See Federal Guidelines for Physical Activity sidebar.) ** The Behavioral Risk Factor Surveillance System (BRFSS) is an annual population-based, random-digit-dialed telephone survey of Americans 18 and older. During 1986-2000, BRFSS included questions that measured leisure-time physical activity that was of vigorous intensity. In the meantime, the Centers for Disease Control and Prevention (CDC) concluded that health-related benefits could be gained from a minimum of 30 minutes of moderate-intensity activity on most days of the week. Thus, in 2001, new physical activity questions were used on BRFSS that more completely measured physical activity than previously. The new lifestyle activity questions classified more persons in the U.S. as physically active (45.4%) than did the leisure-time activity questions asked up until 2000 (26.2%). In California, the new questions resulted in 45.8% of adults being classified as physically active in 2001, in contrast to 28.8% in 2000. The proportion of physically inactive persons remained about the same in California (26.5% in 2000, and 26.6% in 2001).
10

TABLE 2. PERCENT OF STUDENTS FOR GENDER AND RACE/ETHNICITY MEETING MINIMAL PHYSICAL FITNESS STANDARDS, 5TH, 7TH AND 9TH GRADES, 2002-03, CALIFORNIA
5th grade Male Female White Asian Filipino 21.7 24.5 30.5 28.6 24.7 7th grade 25.5 28.8 33.7 35.9 32.9 29.8 21.6 25.2 21.2 9th grade 25.7 22.4 30.5 33.4 27.7 25.5 18.1 19.5 18.4

Physical inactivity translates to lack of physical fitness. The California Department of Education is required by state law to annually test the level of physical fitness of students in the 5th, 7th, and 9th grades. Of the 1.3 million California students tested during school year 2002-03, only 25% met minimal fitness standards, representing a slight increase from 24% in school year 2001-02.48 Girls were more physically fit than boys in grades 5 and 7, but 9th grade boys were more physically fit than girls. Of those who met minimal fitness standards, percentages were higher among Asian, white, and Filipino students than among Latinos and African Americans. Physical fitness was also higher among 7th graders than among 5th or 9th graders from all racial/ethnic groups (Table 2). Physical education (PE) classes in school are one way for children and teens to become more physically fit but, for a variety of reasons, many California students do not meet state-mandated PE requirements. In 1999, among Californias elementary school children, 9 to 11 years old: PE Enrollment. Some 17% reported not taking physical education or gym classes at school. PE Minutes. The average number of PE classes reported per week was 2.3, with a length of 33 minutes per class, an amount that falls nearly one hour short of the 200 PE minutes mandated to occur every 10 days for elementary school children.49 In 2000, enrollment in PE (Table 3) decreased as the age of the student increased for California youth ages 12 to 17.50 Several factors account for poor PE participation: Many California elementary schools do not offer the required PE hours.51,52 Shrinking school budgets erode physical education staffing and programs.53 PE is of uneven quality across schools and school districts.54 PE classes are overcrowded.55 Physical activity and movement are generally not integrated into the regular classroom curriculum, thus isolating PE from more academic subjects.56 Teachers and school boards do not uniformly understand or value the potential of PE.57

Pacific Islander 23.4 African Am. Am. Indian Latino 20.7 20.6 17.3

Source: California Department of Education.(2003, November). 2003 California physical fitness testing: Report to the Governor and the Legislature. Retrieved May 25, 2004, from http://www.cde.ca.gov/ta/tg/pf/documents/govreport2003.pdf

TABLE 3. ENROLLMENT IN PE CLASSES, BY GENDER AND AGE, 1998, CALIFORNIA

Males 12-13 14-15 16-17 93% 83% 55% Females 92% 83% 53%

Source: 2000 California Teen Eating, Exercise and Nutrition Survey (CalTEENS). (2004, Spring). [Data tables]. Sacramento, CA: California Department of Health Services, Cancer Prevention and Nutrition Section.

Of the 1.3 million California students tested during school year 2002-03, only 25% met minimal fitness standards.

11

Consequences of Poor Nutrition, Hunger, and Physical Inactivity

Poor diet and physical inactivity increase the risk for many chronic diseases, including cancer, type 2 diabetes, and cardiovascular disease, and together are responsible for at least 400,000 preventable deaths annually among Americans. The Centers for Disease Control and Prevention predicts that poor eating habits and physical inactivity will soon overtake cigarette smoking as the leading cause of preventable deaths in the United States.58 In California, poor diet and physical inactivity are estimated to prematurely claim over 33,000 lives each year.59 Research shows that: Poor diet and lack of exercise contribute to about one-third of cancer cases. Diet contributes to 40% of high blood pressure (hypertension) and 20% of heart disease cases. Overweight and obesity contribute to about 90% of type 2 diabetes cases.60 The health costs of poor nutrition and childhood overweight are significant in childhood and often last a lifetime.

In California, poor diet and physical inactivity are estimated to prematurely claim over 33,000 lives each year. Overweight children are at risk for many serious health problems that used to be unheard of during childhood, such as high blood pressure, type 2 diabetes, and high cholesterol levels all early warning signs for heart disease.61 Children experiencing food insecurity and hunger are sick more often and have higher rates of ear infections, iron deficiency anemia, and hospitalizations, causing missed school days, diminished capacity to learn, poor mental health, and behavioral problems.62 Even mild malnutrition can limit a childs growth and restrict brain development. Not having enough to eat can limit cognitive development and overall learning potential, and it can cause iron deficiency that reduces the immune response and ability to concentrate.63,64 About half of overweight adolescents become obese adults.65

The High Cost of Obesity, Poor Diet, and Physical Inactivity

The cost of obesity, poor nutrition, and lack of physical activity is staggering. In 2005, costs (medical care, lost employee productivity, and workers' compensation) attributable to obesity, overweight, and physical inactivity are expected to be over $28 billion in California alone.a On the national level: Annual hospital costs related to childhood obesity tripled from $35 million in 1979 to $127 million in 1999.b Annual obesity-attributable medical expenditures are estimated to be $75 billion in 2003 dollars with about one-half of these expenditures paid by Medicare and Medicaid (known as MediCal in California).c The other half is borne by employers and workers in the form of health care premiums, out-of-pocket health costs, and co-pays. Over $42 billion in annual medical costs and lost productivity due to heart disease, cancer, stroke, and diabetes are related to poor diet.d In 2000, health care costs related to physical inactivity were greater than $76 billion. If 10% of the adult population had undertaken a regular exercise regime of walking, $5.6 billion in expenses for heart disease could have been avoided.e
a b c d

Personal communication, September 3, 2004, J. Carman, Manager, California 5 a Day Worksite Program, California Department of Health Services. Wang, G., & Dietz, W. H. (2002, May). Economic burden of obesity in youths aged 617 years: 1979-1999. Pediatrics, 109(5), 81. Finkelstein, E., et al. (2004). State-level estimates of annual medical expenditures attributable to obesity. Obesity Research, 12, 1824.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. (2003, August). Preventing obesity and chronic diseases through good nutrition and physical activity. [Fact sheet]. Retrieved November 30, 2003, from http://www.cdc.gov/nccdphp/pe_factsheets/pe_pa.htm Ibid.

12

THE ROLE

OF

GOVERNMENT
The Federal System
The federal government develops and implements national policy for food assistance programs, nutrition standards and guidelines, and food safety. It also allocates federal funds for a variety of meal and food distribution programs to state, county, city, and tribal governments, as well as to private organizations. The federal government also conducts and disseminates research and implements national educational campaigns. The USDA and DHHS are the principal, but not only, federal agencies involved in these activities, as described below. *

This section briefly describes the federal and state governmental agencies, departments and programs related to nutrition and food assistance. The following section provides further detail on key programs, including those funded by the federal government and implemented through state and local public agencies. The federal government, primarily through the U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (DHHS), plays a central role in funding, regulating, and developing public policy for most public nutrition and food assistance programs. At the state level, the California Departments of Education, Social Services, Health Services, and Aging have key roles in accepting and directing federal dollars, developing and implementing state policy and programs, and monitoring and/or regulating local public, private, and nonprofit entities.

U.S. DEPARTMENT OF AGRICULTURE

The USDA is the primary federal agency responsible for nutrition assistance and food distribution programs and provides nearly $40 billion annually for food and nutrition

Background on U.S. Food Assistance Programs

Nutrition and hunger policies in the U.S. began during the Great Depression with the dual purpose of feeding the hungry by using agricultural surpluses and maintaining price supports for farmers. Faced with widespread child malnutrition in the early 1930s, donated surplus foods became the primary source of support for school lunch and other child feeding programs, eventually resulting in passage of the National School Lunch Act of 1946. The first food stamp program that began in 1939 was discontinued in 1943 when Americas entrance into World War II ended extensive joblessness. Almost 20 years later, President Kennedy signed his first executive order in 1961 initiating food stamp pilot programs and shifting, for the first time, the primary purpose of commodity distribution programs from surplus disposal to providing nutritious foods to needy families. Early food stamp recipients purchased coupons that were equal to what they usually spent on food and, in exchange, received that value in stamps plus bonus stamps to buy food at retail stores. Efforts by the Nixon Administration (1969-73) to phase out commodity donation programs failed as hunger was increasingly identified as a national problem. Instead, new programs were created to meet food needs of infants, children, low-income pregnant or breastfeeding women, Native Americans, and the elderly. In 1970, the National School Lunch Program received a new cash subsidy for schools based on the number of meals served to low-income children; and schools, in return, provided free or reduced-price meals. Funding for the popular Food Stamp Program, the nations largest hunger prevention program, was cut under the Reagan Administration in the early 1980s, only to be followed by incremental expansion within a few years when domestic hunger continued to grow. As unemployment and homelessness increased, emergency food assistance organizations (soup kitchens and food banks) were for the first time guaranteed food commodity assistance from the federal governments Emergency Food Assistance Program. In the early 1990s, major changes in food stamp benefits added nearly $3 billion in benefit increases that swelled participation to 28 million people in 1994. The Food Stamp Program experienced major changes resulting from welfare reform enacted in 1996. Eligibility for most legal immigrants was eliminated, but was later restored for some immigrants when the Food Stamp Program was re-authorized in 2002. The Child Nutrition and WIC Reauthorization Act of 2004 was signed into law in June 2004, reauthorizing key nutrition assistance programs.
Sources: U.S. Department of Agriculture, Food and Nutrition Service. A short history of the Food Stamp Program. Retrieved May 26, 2004, from http://www.fns.usda.gov/fsp/rules/Legislation/history.htm U.S. Department of Agriculture. History of the Food Distribution Programs. Retrieved April 19, 2004, from http://www.fns.usda.gov/ fdd/aboutfdp/ fd-history.pdf * Other federal departments regulate and enforce food safety standards (Food and Drug Administration, Environmental Protection Agency, Department of Justice) and protect consumers from deceptive and unsubstantiated food advertising (Federal Trade Commission). In California, the Division of Food, Drug, and Radiation Safety in the Department of Health Services works to ensure the safety of foods. The work of these agencies is not the focus of this Primer.
13

assistance to low-income households.66 About half the USDA budget supports 15 domestic food assistance programs that serve an estimated 1 in 5 Americans at some point during any year. These programs include: The Food Stamp Program, the largest food assistance program in the country, helps low-income Americans purchase food and offers states the options of sharing costs to provide nutrition education to promote healthy eating and conducting outreach activities to increase participation in the program. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides food vouchers and nutrition education to eligible low-income pregnant, postpartum, and breastfeeding women, as well as children under five years old at nutritional risk. Child Nutrition Programs provide cash reimbursements for USDA-supported meals served to eligible students, young children, and vulnerable adults through the National School Lunch Program, School Breakfast Program, Special Milk Program, Summer Food

Service Program, and Child and Adult Care Food Program. Older adults are primarily served through Congregate Nutrition Services and Home-Delivered Meal Services programs. Food distribution programs include the Emergency Food Assistance Program, Commodity Supplemental Food Program, Food Distribution Program on Indian Reservations, and the Food Distribution Disaster Assistance Program. In addition, food is distributed through some Child Nutrition Programs, such as the National School Lunch Program. Nutrition policy and education programs within USDA include: The Cooperative State Research, Education, and Extension Service (CSREES), through the agricultural extension systems of land grant universities, supports programs and national initiatives for educational programming. CSREES Expanded Food and Nutrition Education Program (EFNEP) operates in all 50 states and is designed to provide low-income Americans with information about nutritionally sound diets.

U.S. Department of Agriculture: Key Nutrition Programs

U.S. Department of Agriculture (USDA)

Economic Research Service

Food, Nutrition and Consumer Services

Cooperative State Research, Education, and Extension Service (CSREES)

Food, Nutrition and Consumer Services

Center for Nutrition Policy and Promotion

Food Stamp Program

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

Child Nutrition Programs

Food Distribution Programs

Expanded Food and Nutrition Education Program

Food Stamp Nutrition Education Program

School Breakfast Program National School Lunch Program Summer Food Service Program Special Milk Program Afterschool Snack Program Child and Adult Care Food Program

Emergency Food Assistance Program Commodity Supplemental Food Program Food Distribution Program on Indian Reservations Food Distribution Disaster Assistance

14

The Center for Nutrition Policy and Promotion (CNPP) develops and coordinates nutrition policy within USDA and, in conjunction with DHHS, publishes the Dietary Guidelines for Americans and the Food Guide Pyramid. The Economic Research Service (ERS) is the main source of economic information and research from USDA on economic and policy issues related to agriculture, food, natural resources, and rural development. In addition, the National Food Service Management Institute, permanently authorized by Congress in 1994 and based at the University of Mississippi, offers education, research, and other resources for Child Nutrition Programs throughout the country.

and recommendations on nutrition, obesity prevention, and physical activity. It administers chronic disease categorical programs, prevention centers, the Preventive Health and Health Services Block Grant, school health, and several national surveys. The National Center's Division of Nutrition and Physical Activity conducts epi demiological and behavioral research, training, and health promotion and works towards policy and environmental change. In California, the CDC helps fund Project LEAN, the California 5 a Day for Better Health! Campaign, the California Center for Physical Activity, the California Obesity Prevention Initiative, the Diabetes Prevention and Control Program, WISE WOMAN (a demonstration project), the Coordinated School Health program, called School Health Connections in California, and the Behavioral Risk Factor Survey. The National Health and Nutrition Examination Surveys (NHANES) are conducted on an on-going basis by the National Center for Health Statistics in the CDC. The surveys are designed to obtain nationally representative information on the health and nutritional status of the U.S. population through interviews and direct physical examinations.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Several entities within DHHS are involved in research and a variety of nutrition, physical activity, and food safety programs. These include: The Centers for Disease Control and Prevention (CDC) is home to the National Center for Chronic Disease Prevention & Health Promotion, which develops guidelines

U.S. Department of Health and Human Services: Key Nutrition Programs

Department of Health and Human Services (DHHS)

Administration on Aging

Centers for Disease Control and Prevention (CDC)

Food and Drug Administration (FDA)

National Institutes of Health (NIH)

Assistant Secretary for Health

National Center for Chronic Disease Prevention and Health Promotion

National Center for Health Statistics

National Cancer Institute

National Heart, Lung and Blood Institute

Office of Public Health and Science

Division of Nutrition and Physical Activity Division of Adolescent and School Health

National Health & Nutrition Examination Survey (NHANES)

5 A Day for Better Health Program

Office of Disease Prevention and Health Promotion

Office of the Surgeon General

Presidents Council on Physical Fitness and Sports

15

The National Institutes of Health (NIH) is the steward of medical and behavioral research in the United States. Among its 27 institutes and centers, the National Cancer Institute is the lead health authority for the national 5 A Day Program. The National Heart, Lung and Blood Institute coordinates an obesity education initiative to reduce heart disease. The Food and Drug Administration (FDA) monitors food safety, as well as nutrition and ingredient labeling. FDAs new initiative Calories Count includes an action plan to address the nations obesity problem. The Administration on Aging receives commodity foods from USDA and administers the Older Americans Act Nutrition Programs which support congregate and home-delivered meal programs. The Office of the Surgeon General focuses on major national public health issues, including nutrition, physical activity, and obesity, and provides oversight for Healthy People 2010. The Office of Disease Prevention and Health Promotion publishes the Healthy People series of national health goals every ten years, and jointly publishes, with USDA, Dietary Guidelines for Americans every five years.

The Presidents Council on Physical Fitness and Sports advises the President and the Secretary of Health and Human Services about how to encourage more Americans to be physically fit and active.

DEPARTMENT OF DEFENSE
The Department of Defense, through a partnership with USDA called the Fresh Fruit and Vegetable Project, distributes high quality fresh fruits and vegetables at a minimal cost for use in school meal programs.

DEPARTMENT OF EDUCATION
The Office of Safe and Drug-Free Schools, within the Department of Education, awards grants to local educational agencies and community-based organizations to initiate, expand, or improve physical education programs, including after-school programs for students in one or more grades from kindergarten to 12th grade. These Physical Education Program (PEP) grants are intended to help students make progress toward meeting state standards for physical education. Approximately $59 million in grants were distributed nationally in 2003.

U.S. Department of Defense: Key Nutrition Program

U.S. Department of Education: Key Physical Education Program

Department of Defense

Department of Education

Defense Personnel Support Center

Office of Safe and Drug Free Schools

Fresh Fruit and Vegetable Project

Physical Education Program (PEP)

16

Key Federal Legislation

Below is a chronology of key federal legislation related to nutrition, food security, and physical activity. As noted below, a number of these laws must be periodically reauthorized. Agricultural Adjustment Act Amendment, 1935 Public Law (P.L.) 74-320 authorizes diversion of surplus agricultural commodities from the normal channels of trade and commerce and provides the basis for donating surplus commodities to federal domestic food programs. National School Lunch Act, 1946 P.L. 106-224 provides commodity and cash support to schools participating in the lunch program. Agricultural Act, 1949 P.L. 89-439 makes certain commodities acquired through price-support operations available for distribution to needy people, e.g., through school lunch programs and the Bureau of Indian Affairs. Food Stamp Act, 1964 P.L. 88-525 creates a permanent Food Stamp Program (FSP), which has been amended many times. P.L. 91-671 (1971) establishes uniform national standards of eligibility and work requirements; P.L. 93-86 (1974) authorizes FSP to operate nationwide; P.L. 88-525 (1977) establishes the poverty level as the eligibility criterion for recipients and sets forth products that stores must sell to become authorized vendors. The latest reauthorization of FSP occurred in the 2002 Farm Bill (P.L. 107-171). Older Americans Act, 1965 P.L. 89-73 creates a coordinated system at the state and local levels to organize and deliver community-based services for older Americans, especially those at risk of losing their independence. P.L. 92-258 (1972) adds a national nutrition program for the elderly. P.L. 100-175 (1987) authorizes participation of eligible adult day care centers in the Child and Adult Care Food Program. Child Nutrition Act, 1966 Adopted first as P.L. 89-642 and subsequently amended and reauthorized most recently as the Child Nutrition and WIC Reauthorization Act of 2004. Now authorizes, among many provisions, the School Breakfast Program, the National School Lunch Program, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the Child and Adult Care Food Program, and the Summer Food Service Program, as well as including provisions for nutrition education. Special Supplemental Nutrition Program for Women, Infants and Children (WIC), 1972 P.L. 92-433 formally authorizes a two-year demonstration program by amendment to the Child Nutrition Act of 1966, and P.L. 94-105 (1975) makes WIC a permanent national health and nutrition program. Reauthorized in June 2004 through the Child Nutrition and WIC Reauthorization Act of 2004. Agriculture and Consumer Protection Act, 1973 P.L. 93-86 requires states to expand the Food Stamp Program to every political jurisdiction and to serve substance abusers in treatment centers. Also requires USDA to establish temporary eligibility standards for disasters. The Temporary Emergency Food Assistance Act, 1983 P.L. 98-8 establishes the Temporary Emergency Food Assistance Program (TEFAP) to provide food to local emergency food providers. The word Temporary was dropped from the statute and program title in 1990. Hunger Prevention Act, 1988 P.L. 100-435 amends the TEFAP Act (1983) to make available additional commodities, improves child nutrition and Food Stamp Programs, and mandates development of performance standards for the Food Stamp Employment and Training Program. National Nutrition Monitoring and Related Research Act, 1990 P.L. 101-445 establishes the National Nutrition Monitoring and Related Research Program to strengthen food and nutrition data collection through survey and surveillance activities and to develop a 10-year strategic plan. Requires a joint USDA/DHHS review process for all federal nutrition guidance materials. Nutrition Labeling and Education Act, 1990 P.L. 101-535 requires nutrition labels disclosing fat, cholesterol, sodium, sugar, fiber, protein, and carbohydrate content on nearly all packaged foods. Exempts food sold in certain venues, including restaurants and prepared food counters. Also requires FDA to establish standards for food descriptors (low, lean, light, etc.) and sets standards to allow health claims based on scientific evidence. Intermodal Surface Transportation Efficiency Act (ISTEA), 1991, and Transportation Equity Act (TEA-21), 1998 P.L. 102-240 requires a 10% set-aside of Surface Transportation Program funding for bicycle and pedestrian facilities; and P.L. 105-178 expands provisions to make bicycling and walking safer and more viable modes of travel. The third iteration of the act, TEA-3, is in the process of being reauthorized. Breastfeeding Promotion, 1991 P.L. 102-342 requires USDA to establish a national breastfeeding promotion program. Mickey Leland Childhood Hunger Relief Act, 1993 P.L. 103-66 increases food stamp benefits to low-income families with children. The Healthy Meals for Healthy Americans Act, 1994 P.L. 103-448 extends free meal eligibility to most children in Head Start. The Personal Responsibility and Work Opportunities Reconciliation Act, 1996 P.L. 104-193 eliminates food stamp eligibility of drug felons and most legal immigrants and places time limits on other food stamp recipients. Freedom to Farm Act, 1996 P.L. 104-127 establishes the Community Food Projects Program. The Farm Bill, 2002 P.L. 107-171 reauthorizes the Food Stamp Program for five years and restores food stamp eligibility to many qualified immigrants. Allows states to certify food stamp benefits for an additional five months after families leave the Temporary Assistance for Needy Families (formerly AFDC) program and provides a variety of options to streamline administration. The Free Fruit and Vegetable Pilot was established in four states and on one Indian reservation.

17

The State System

The California Department of Education (CDE) is responsible for a vast network of meal and food distribution programs in the state. Within the California Health and Human Services Agency, the Departments of Health Services (CDHS), Social Services (CDSS), and Aging (CDA) administer a number of food assistance and educational programs and conduct research on nutrition and physical activity. Other state entities also have key roles,

including the Department of Food and Agriculture (CDFA) and the University of California Cooperative Extension (UCCE). These entities are described on the following pages. California currently receives about $3.7 billion a year in federal nutrition and food assistance funds (Table 4). Some of these programs are mandatory, while others are discretionary. Most exclusively serve low-income individuals. For some nutrition programs, the state and counties are required to pay a portion of administrative costs.

TABLE 4. FEDERAL FUNDING

Year(s) School Year 2002-2003 School Year 2002-2003 July 2002 FFY 2003* FFY 2003 FFY 2003** FFY 2003*** FFY 2003 FFY 2002 FFY 2002 FFY 2002

FOR

NUTRITION

AND

FOOD ASSISTANCE PROGRAMS

IN

CALIFORNIA

Administering State Department DEPARTMENT OF EDUCATION School Breakfast Programa National School Lunch Programa Summer Nutrition Programa Child and Adult Care Food Programa Commodity Supplemental Food Programa DEPARTMENT OF SOCIAL SERVICES Food Stamp Programa Emergency Food Assistance Programa DEPARTMENT OF HEALTH SERVICES WICa California Nutrition Networkb DEPARTMENT OF AGING Congregate Meal Programc Home Delivered Mealsc UNIVERSITY OF CALIFORNIA COOPERATIVE EXTENSION

Funds Received ($) 213,116,962 853,839,365 14,337,552 206,724,214 2,763,748 1,808,411,792 55,610,255 810,180,009 53,866,893 33,711,000 30,759,000

FFY 2002
Notes: * FFY = Federal Fiscal Year

Food Stamp Nutrition Education Programd

4,375,355

**Includes nutrition education efforts subcontracted to the California Nutrition Network (California Department of Health Services) and Food Stamp Nutrition Education Program (University of California Cooperative Extension). ***The Emergency Food Assistance Program (TEFAP) funding includes $17,151,710 in federal entitlement funds, $30,488,426 in federal bonus commodity funds, and $7,970,119 in administrative funds. Sources:
a Hess, D., & Weill, J. (2004, April). State of the states 2004: A profile of food and nutrition programs across the nation. Washington, D.C.: Food Research and Action Center. Available from the Food Research and Action Center website, http://www.frac.org b

Personal communication, April 19, 2004, R. Bonitz, Manager, Administrative Unit, Cancer Prevention and Nutrition Section, California Department of Health Services. Personal communication, May 12, 2004, M. Marsom, Development Specialist, Cancer Prevention and Nutrition Section, California Department of Health Services. Personal communication, April 29, 2004, R. Bonitz, Manager, Administrative Unit, Cancer Prevention and Nutrition Section, California Department of Health Services.

18

California Department of Education: Key Nutrition and Physical Education Programs

Superintendent of Public Instruction

Department of Education

Assessment & Accountability Branch

School & District Operations Branch

Curriculum & Instruction Branch

Standards & Assessment Division

Nutrition Services Division

Professional Development and Curriculum Support Division

Learning Support & Partnerships Division

Assessment Office Physical Fitness Test Nutrition Programs Food Distribution Section

Physical Education Consultant

School Health Connections and Healthy Start Office (works jointly with CDHS)

Commodity Distribution Unit

Commodity Supplemental Food Program

National School Lunch Program School Breakfast Program Summer Food Service Program Special Milk Program Child & Adult Care Food Program Components: Adult Day Care Child Care (Centers/Homes) Emergency Shelter Nutrition Initiatives: Garden in Every School Initiative LEAF SHAPE California

19

California Health and Human Services Agency: Key Nutrition Programs

California Health and Human Services Agency

Department of Aging

Department of Health Services

Department of Social Services

Long-Term Care and Aging Services Division

Division of Chronic Disease and Injury Control

Primary Care and Family Health Division

Welfare Programs Division

Division of Welfare to Work

Long-Term Care Branch

Office of Womens Health Brown Bag Program

The Emergency Food Assistance Program

Food Stamp Branch

Congregate Nutrition Services

Home Delivered Meals

Food Stamp Program

California Food Assistance Program

Cancer Control Branch

Epidemiology & Prevention for Injury Control Branch

Chronic Disease Control Branch

WIC Branch

Maternal and Child Health Branch

Childrens Medical Services Branch

Cancer Prevention & Nutrition Section

Cancer Surveillance Section

Cancer Detection Section

State and Local Injury Control Section

Epidemiology & Health Promotion Section

Child Health and Disability Prevention Program (CHDP)

California 5 a Day for Better Health! Campaign California Nutrition Network for Healthy, Active Families Physical Activity Integration Unit California Dietary Practices Survey CalTEENS CalCHEEPS

California Behavioral Risk Factor Survey

Healthy Lifestyles WISEWOMAN

Safe Routes to School*

California Project LEAN California Center for Physical Activity California Obesity Prevention Initiative Diabetes Prevention and Control Program School Health Connections

* Also administered by the California Center for Physical Activity

20

DEPARTMENT OF EDUCATION
The Nutrition Services Division of the California Department of Education (CDE) administers the following USDA Child Nutrition Programs: The National School Lunch Program provides daily nutritionally balanced, low-cost or free lunches. The School Breakfast Program provides daily nutritionally balanced, low-cost or free breakfasts. The Summer Food Service Program provides meals to children when they are out of school for 15 or more consecutive days. The Child and Adult Care Food Program provides funding for meals served in a child care setting to children up to age 13 and in adult care centers to impaired adults. The Special Milk Program assists schools and other agencies by providing milk to children at low prices. The Nutrition Services Division also administers a number of USDA food distribution programs that provide commodity foods to schools and other food assistance programs, such as local emergency assistance agencies and disaster relief organizations, as well as some specified low-income households. In addition, the Nutrition Services Division participates in USDAs Team Nutrition Program and a variety of initiatives such as SHAPE (Shaping Health as Partners in Education) California. The Division provides SHAPE California schools with resources, technical assistance, and training. The LEAF (Linking Education, Activity and Food) initiative reflects the intent of Senate Bill 19 to implement and pilot test changes in school nutrition and physical activity policies and practices to improve children's lifelong health. The Nutrition Services Division is also home to the Garden in Every School Initiative, which was launched by CDE in 1995. School gardens and garden-enhanced nutrition education foster improved student health, and they connect to a schools core curriculum and food services. Students who participate in school gardens discover fresh foods and eat more fruit and vegetables. The Garden in Every School Initiative provides a variety of services to individuals and organizations that support school gardens, including a free packet of garden start-up information. School Health Connections (Californias name for the federal Coordinated School Health program funded by the Centers for Disease Control and Prevention) is based in the Learning Support and Partnerships Division of CDE and administered in partnership with the California Department of Health Services. The program promotes a healthy lifestyle among children and youth by providing information in eight priority areas, including nutrition, physical activity, and the dangers of tobacco and other drugs.

DEPARTMENT OF SOCIAL SERVICES

The California Department of Social Services (CDSS) administers the following food assistance programs: The Food Stamp Program (FSP) provides monthly food stamps to eligible low-income households and individuals. The California Food Assistance Program is a state-funded program that provides food assistance to legal immigrants who lost food stamp eligibility under federal welfare reform in 1996 and who have been legally residing in the country less than 5 years. The Emergency Food Assistance Program (TEFAP) provides emergency food and nutrition assistance to low-income households and individuals and to congregate feeding sites.

DEPARTMENT OF HEALTH SERVICES

The California Department of Health Services (CDHS) develops and implements statewide nutrition and physical activity campaigns and programs, conducts surveys and intervention research, and provides supplemental food to special need populations. Nutrition and physical activity programs are housed in all three branches of the Division of Chronic Disease and Injury Control: Within the Cancer Control Branch: The Cancer Prevention and Nutrition Section (CPNS) implements large-scale campaigns geared to correct problems of poor diet, physical inactivity, and food insecurity. CPNS manages the California Nutrition Network for Healthy, Active Families, the California 5 a Day for Better Health! Campaign, and the California Physical Activity Integration Unit. In partnership with the Food Stamp Program at CDSS, CPNS supports a regional infrastructure and over 180 local and special projects aimed at increasing fruit and vegetable consumption, physical activity, and food security. Special projects include leadership initiatives with the California Elected Women's Association, California Food Policy Advocates, the California Medical Association Foundation, the California Center for Research on Women and Families, and the Center for Civic Partnerships, home of California Healthy Cities and Communities. CPNS administers the biennial California Dietary Practices Survey of adults, the California Teen Eating, Exercise and Nutrition Survey (CalTEENS), and the California Childrens Healthy Eating and Exercise Practices Survey (CalCHEEPS). The Cancer Surveillance Section conducts the California Behavioral Risk Factor Survey. In the Cancer Detection Section, all 14 regional partnerships provide Healthy Lifestyles information to lower-income
21

older women, and the section is piloting WISEWOMAN, a heart disease-oriented nutrition intervention. The Chronic Disease Control Branch is home to: The Epidemiology and Health Promotion Section which administers California Project LEAN (Leaders Encouraging Activity and Nutrition), the California Center for Physical Activity, the California Obesity Prevention Initiative, the Diabetes Prevention and Control Program, and School Health Connections (a partnership with the Department of Education). The Epidemiology and Prevention for Injury Control Branch (EPIC) administers the Safe Routes to School Program within the State and Local Injury Control Section. The Primary Care and Family Health Division administers: The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides food vouchers and nutrition education to low-income pregnant, postpartum, and breastfeeding women, as well as to children under five who are at medical or nutritional risk. The Maternal and Child Health Branch annually evaluates county MCH programs on the childhood obesity performance indicator and includes nutrition and physical activity components in its programs. The Childrens Medical Services Branch houses the Child Health and Disability Prevention (CHDP) Program which administers the Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT). EPSDT offers preventive health assessments for children and youth up to age 21 in low-income families. The Office of Womens Health, located in the CDHS Directors Office, directs the annual California Womens Health Survey of health-related attitudes and behaviors. Questions about breastfeeding, nutrition, and food security are included in this survey.

fresh produce at certified farmers markets during the growing season. The Brown Bag Program provides surplus and donated fresh produce and other food products monthly to lowincome seniors at community sites.

UNIVERSITY OF CALIFORNIA COOPERATIVE EXTENSION

The University of California Cooperative Extension (UCCE) is the outreach arm for the Division of Agriculture and Natural Resources for the University of California. UCCE serves every county in the state through three regional offices: the Northcoast and Mountain region, the Central Valley region, and the Central Coast and South region. Based in county offices, UCCE nutrition, family, and consumer sciences advisors provide services, training, and educational materials on nutrition, food safety, food preparation, food preservation, and finance management. Relevant programs include: Expanded Food and Nutrition Education Program (EFNEP), funded through USDA and administered by UCCE, conducts nutrition outreach. EFNEP operates an adult nutrition education program in 16 counties to participants recruited from WIC, Head Start, and Food Stamp programs. In 10 counties, youth programs are offered in schools, after-school programs, day camps, and preschools. California Food Stamp Nutrition Education Program (FSNEP) operates in 38 counties through a joint agreement among USDA, CDSS, and UCCE. FSNEP offers an adult program to improve the nutrition-related skills of food stamp recipients. Nutrition education is also provided to youth at schools and community programs with large numbers of children from food stamp households. While program offerings vary, UCCE offices throughout the state also administer 4-H and Master Gardener programs, as well as education on obesity, healthy eating, diabetes, and school gardens.

DEPARTMENT OF AGING
The California Department of Aging (CDA) administers programs funded by the federal Older Americans Act through the network of Area Agencies on Aging and their service providers. The Department also uses state general fund dollars to fund the Brown Bag Program. Nutrition programs include: Congregate Nutrition Services provides meals in a group setting to seniors age 60 and older. Home-Delivered Meal Services provides meals to housebound seniors. The Senior Farmers Market Nutrition Program provides $20 coupons annually to low-income seniors to purchase
22

DEPARTMENT OF FOOD AND AGRICULTURE

The Department of Food and Agriculture (CDFA) protects California's food supply from pests and diseases. CDFA oversees over 50 marketing programs, including Buy California. These marketing programs conduct industrysupported promotion and marketing, as well as research and inspection of agricultural products, including many fruits, vegetables, nuts, and dairy, seafood and animal products. CDFA regulates California's Certified Farmers' Markets where fresh picked crops are sold directly to the public in over 350 communities. CDFA also oversees 78 county fairs that serve as family-oriented educational venues.

Key State Legislation

Below is a chronology of key California state legislation related to nutrition, food security, and physical activity. Senate Bill (SB) 942 (Chapter 404, Statutes of 1937) establishes the California Marketing Act of 1937 which provides authority for the agriculture industry to form and self-fund 25 marketing programs (marketing orders and agreements) for a wide variety of agriculture commodities under the direction of the California Department of Food and Agriculture. Functions of these entities may include research, quality inspection, domestic and international trade promotion, advertising, merchandising, and consumer and nutrition education. Comparable legislation was subsequently adopted to authorize 25 additional marketing programs. SB 120 (Chapter 1277, Statutes of 1975) establishes the State Meal Program requiring public school districts and county school superintendents to make one free or reduced-price nutritionally adequate meal available to each needy student every school day. SB 1178 (Chapter 1405, Statutes of 1986) establishes the California Nutrition Monitoring Development Act of 1986. Senate Concurrent Resolution (SCR) 93 (1988) establishes the annual state per capita goal of 500 pounds of fruit and vegetables, or 5 servings a day. Assembly Bill (AB) 2109 (Chapter 614, Statutes of 1989) requires the California Department of Education (CDE) to establish and maintain state standards for a nutritionally adequate school breakfast and lunch and for all foods sold on public school campuses. Requires CDE to consider recommendations in the California Daily Food Guide established by the California Department of Health Services (CDHS). AB 2181 (Chapter 85, Statutes of 1991) established the taxation of cookies, candy, and other snack foods in an effort to bridge the gap between state revenues and expenditures. Proposition 163, passed by voters on the November 1992 ballot, repealed the "snack tax" and prohibited future taxation of these products. AB 1902 (Chapter 415, Statutes of 1992) requires CDHS to establish and implement the California 5 a Day for Better Health! Campaign to increase the consumption of fruits and vegetables. AB 265 (Chapter 6, Statutes of 1995) mandates school districts to conduct an annual standardized physical fitness test to all 5th, 7th, and 9th graders. Assembly Concurrent Resolution (ACR) 58 (1997) requires the Administration to appoint a Blue Ribbon Task Force to recommend policies and actions in food safety and quality, nutrition and health, nutrition education and marketing, and food security, supply, and delivery. AB 606 (Chapter 174, Statutes of 1997) requires CDE to prepare a report on specified school nutrition issues. SB 273 (Chapter 756, Statutes of 1997) creates the California Cancer Research Program in CDHS and provides funds for cancer prevention, including intramural and extramural research for diet and lifestyle. SB 896 (Chapter 1066, Statutes of 1998) requires CDE to submit every 2 years to the Legislature and Governor a report of physical education test results for grades 5, 7, and 9. To the degree funding is available, also requires CDE to track development of high quality fitness programs and compare performance of California's students with national counterparts. SB 2013 (Chapter 682, Statutes of 2000) requires CDSS to simplify and shorten food stamp application forms. AB 59 (Chapter 894, Statutes of 2001) authorizes improved information sharing and coordination of eligibility processes between Medi-Cal and the National School Lunch Program. AB 429 (Chapter 1111, Statutes of 2001) makes permanent the California Food Assistance Program, which was first created in 1998. SCR 40 (2001) creates the California Task Force on Youth and Workplace Wellness to study and promote fitness and health in schools and workplaces. SB 10 (Chapter 600, Statutes of 2001) extends through 2004 a pilot program to make it safer for children to walk and bike to school by building new crosswalks, sidewalks, pedestrian and bicycle paths, and bike lanes, and lowering the speed limit around schools. SB 19 (Chapter 913, Statutes of 2001) establishes nutrition standards for food sold at elementary schools, limits availability of carbonated beverages in middle schools, and increases state school meal reimbursements. Funds needed to increase state meal reimbursements were not included in the 2003 state budget, thereby delaying implementation planned for January 2004. SB 493 (Chapter 897, Statutes of 2001) Increases outreach and simplifies eligibility process for food stamp recipients to enroll in Medi-Cal and the Healthy Families Program. AB 1634 (Chapter 1163, Statutes of 2002) encourages CDE to develop nutrition education curriculum for grades K-12, and requires competitive grants to be available for school districts to start or expand instructional school gardens. AB 1793 (Chapter 943, Statutes of 2002) requires CDE to monitor the number of hours of physical education (PE) instruction offered to students in grades 1-12 and requires the Board of Education to adopt content standards for PE. SB 1868 (Chapter 1166, Statutes of 2002) requires CDE to encourage school districts, to the extent resources are available, to provide quality PE that develops knowledge, attitudes, skills, behavior, and motivation needed for physical fitness. ACR 16 (2003) requests state agencies to develop nutritionally sound school lunch menu plans that include daily vegetarian options. AB 195 (Chapter 550, Statutes of 2003) specifies that pupils may receive instruction on, among other topics, preventive health care, including nutrition, obesity, and diabetes. With some exceptions, would prohibit entities participating in the program from marketing their services. AB 231 (Chapter 743, Statutes of 2003) allows a food stamp recipient to own a reliable car to get to work by exempting the value of all vehicles when determining eligibility for the Food Stamp Program. Also provides 5 months of transitional food stamp benefits for families moving from welfare to work and allows disabled or elderly applicants to more easily waive in-person interview requirements for food stamps. SB 65 (Chapter 458, Statutes of 2003) requires that school districts provide parents, students, and others an opportunity to comment on proposed contracts with companies that would sell carbonated beverages at local schools. Would prohibit a confidentiality clause in any such contracts. SB 78 (Chapter 459, Statutes of 2003) requires CDE to encourage schools offering K-12 to provide quality physical education and provide extracurricular physical fitness programs. Authorizes schools to give PE test results orally as the student completes testing. Delays until July 1, 2007, the requirement that a pupil pass a physical performance test as a condition of receiving a two-year exemption from PE in grades 10-12 and requires that exemptions not create new programs or service requirements for schools. SB 677 (Chapter 415, Statutes of 2003), the California Childhood Obesity Prevention Act, prohibits the sale of certain beverages to pupils in elementary, middle, or junior high schools commencing July 1, 2004, with exemptions of certain beverages at specified school events. SB 875 (Chapter 879, Statutes of 2003) requires CDHS to develop/obtain a brochure to educate pregnant women and new parents about preventing chronic diseases, having a diet rich in fruits and vegetables, and being active daily.

23

PUBLIC NUTRITION

AND IN

FOOD ASSISTANCE PROGRAMS

Most households are allowed up to $2,000 in countable resources (e.g., checking/savings account, cash, stocks/ bonds). Households with at least one member who is disabled or age 60 or older are allowed up to $3,000 in resources. Able-bodied persons ages 18 to 49 years without dependents are required to work 20 hours per week (or average 80 hours a month), participate 20 hours per week in an approved work activity, or do workfare. If they do not meet one of these requireiments, they are limited to only 3 months of food stamps out of a 36-month period. Most legal immigrants in the United States who are children, elderly, or disabled are eligible to receive food stamps, while undocumented immigrants and some legal immigrants are ineligible for these benefits.

CALIFORNIA

This section describes in more detail the primary public nutrition and food assistance programs operating in California, including the Food Stamp Program, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), Child Nutrition Programs, communitybased child and adult food programs, and food distribution programs.

Food Stamp Program

The Food Stamp Program (FSP) is the largest nutrition program in the country, helping low-income Americans buy food.* Of the approximately 19 million Americans that received food stamps every month in 2002,67 about 1.7 million were Californians.68 Participants may purchase breads and cereals, fruits and vegetables, meats, fish and poultry, and dairy products at most grocery stores and at farmers markets that accept food stamps. To minimize the stigma of receiving food stamps, recipients in California now receive their benefits through an electronic debit card. This more modern method, which replaces paper coupons, was fully implemented throughout California in July 2004. Of the approximately 19 million Americans that received food stamps every month in 2002, about 1.7 million were Californians. In California, 58 county welfare or social service departments operate over 350 FSP offices statewide.69 The average monthly FSP benefit in FFY** 2002 was about $80 per person and $197 per household.70 Of all Californians receiving food stamp benefits, 68% are children.71 Some 70% of food stamp recipients participate in CalWORKs, 80% are female single heads of household, 19% are elderly or disabled, and 40% of households report earning some income.72 Of those receiving food stamps, Latinos account for the largest racial/ethnic group (45%), followed by whites (23%), African Americans (19%), and other, including Asians (13%).73 USDA fully funds FSP benefits and one-half the administrative costs, with the state and counties sharing the other half. FSP is an entitlement program which means that anyone who meets eligibility requirements is entitled to receive benefits. Eligibility is based on financial and non-financial factors.74 The maximum gross income allowed is 130% of the federal poverty level (FPL).
* Food stamp recipients can also purchase seeds and plants to grow food.

Nutrition Education Food Stamps

USDAs Food and Nutrition Service funds states to provide nutrition education programs that encourage food stamp recipients to make healthy food choices and choose active lifestyles. In FFY 2003, California qualified for $62 million in matching funds from the federal government to implement nutrition education among food stamp recipients in California,a,b through the Food Stamp Nutrition Education Program (FSNEP) and the California Nutrition Network. These programs operate through interagency agreements between CDSS, the University of California Cooperative Extension (UCCE) at Davis, and CDHS. FSNEP operates in more than 30 California counties and offers both adult and youth programs,c all of which are developed using the USDA Food Guide Pyramid and Dietary Guidelines for Americans, 2000. The California Nutrition Network serves all 58 counties through 12 regional lead agencies, funding over 180 projects in nearly 4,000 school and community sites in 2004.d
U.S. Department of Agriculture. (2003, August 13). Approved federal funds for Food Stamp nutrition education by state. Retrieved March 2, 2004, from http:// www.nal.usda.gov/foodstamp/pdf/FSPNutritionEducationII.pdf
b a

Personal communication, April 2, 2004, P. Sutherland, Food Stamp Branch, California Department of Social Services.

University of California, Davis. Introduction to the Food Stamp Nutrition Education Program. Retrieved May 26, 2004, from http://fsnep.ucdavis.edu/ intro/default.htm
d

Personal communication, April 20, 2004, S. B. Foerster, Chief, Cancer Prevention and Nutrition Section, California Department of Health Services.

** The Federal Fiscal Year (FFY) is from October 1 through September 30. For example, FFY 2002 is from October 1, 2001 to September 30, 2002. The State of California Fiscal Year (FY) is from July 1 through June 30.
24

Major Nutrition and Physical Activity Programs in the California Department of Health Services
California 5 a Dayfor Better Health! Campaign http://www.dhs.ca.gov/ps/cdic/cpns/ca5aday/default.htm Since 1988, California 5 a Dayor Better Health! Campaign has worked through public/private partnerships to increase fruit and vegetable consumption. Currently, its special initiatives target children (ages 9-11), lower-income Latino families, and lower-income African American adults, along with neighborhood food stores and workplaces. Californias early success inspired the national 5 A Day Program in 1991, since adopted as a voluntary initiative by the other 49 states and the World Health Organization. Recently, the Campaign has added promotion of physical activity, policy and environmental change as priorities. It works in close partnership with sister state agencies for Education, Food and Agriculture, and Social Services, the produce industry, and three departments in the federal government. California Nutrition Network for Healthy, Active Families http://www.dhs.cahwnet.gov/cpns/network/ This multilevel public/private partnership uses social marketing strategies to promote fruits and vegetables, physical activity, and food security among low-income families with children. With matching funds from the USDA Food Stamp Program, the Network contracts with over 180 regional and local projects. The Network sponsors leadership groups, formative and survey research, media and retail campaigns, a Local Incentive Award program, special projects, and policy analysis. Statewide partners include sister state departments, agriculture marketing orders, supermarket chains, trade organizations, the American Cancer Society, other voluntary health agencies, and consumer advocate groups. California Physical Activity Integration Campaign http://www.ca5aday.com/pa/index.htm The Campaign provides leadership to the California 5 a Day for Better Health! Campaign and California Nutrition Network for statewide physical activity initiatives, integrated physical activity and nutrition education, physical activity pilot projects, and statewide physical activity policy. California Project LEAN http://www.californiaprojectlean.org/ California Project LEAN (CPL) works with state and local physical activity and nutrition leaders conducting programs in communities throughout the state to increase healthy eating and physical activity to reduce the prevalence of chronic diseases. CPLs campaigns include Food on the Run for teens in high school, School Board Nutrition Policy Project, and California Bone Health Campaign for Low-Income Latino Mothers. California Center for Physical Activity (formerly Physical Activity and Health Initiative) http://www.caphysicalactivity.com The Center works through alliances with national physical activity experts, local health departments, community-based organizations, and others in the public and private sectors to provide mini-grants, technical assistance, and model programs to promote everyday physical activity through active community environments. Projects include Walkable Community Workshops, Healthy Transportation Network, the California Walk to School Headquarters website (www.cawalktoschool.com), Walkable Neighborhoods for Seniors, Active Aging Community Task Forces, and the Take Action! website (www.ca-takeaction.com). California Obesity Prevention Initiative (COPI) http://www.californiaprojectlean.org/programs/obesity/ California was one of 12 states to win a grant from the Centers for Disease Control and Prevention in 2000. COPI partners with national, state, and local organizations focusing on reducing lifelong risks and health disparities related to obesity by creating environments that support healthy eating and physical activity, especially for youth. Major projects include the statewide Reversing the Obesity Epidemic: Californias Plan for Action, a pilot project to promote quality physical education and improved physical environments for 40 low-resource schools in San Diego, tools to reduce television viewing time of girls ages 11-14, and partnering to increase youth involvement in state and local policy issues related to obesity. Diabetes Prevention and Control Program http://www.caldiabetes.org/ This program focuses on surveillance, quality improvement of diabetes care, health communications and collaborative projects covering a variety of diabetes topics including raising public awareness about diabetes, and initiating or sustaining public health policy for diabetes. Safe Routes to School http://www.dhs.cahwnet.gov/epic/sr2s/ This program provides $20 million per year through the Department of Transportation to local California communities for projects to construct new sidewalks, crosswalks, pedestrian and bike paths, and bike lanes. Special Supplemental Nutrition Program for Women, Infants and Children (WIC) http://www.wicworks.ca.gov/ (See page 26 for program description.)

25

California Sanctioned for High Food Stamp Error Rate, Challenged on Low Participationa
California has been appealing a $114 million penalty for Federal Fiscal Year (FFY) 2001 and a lower but still hefty $60 million fine for FFY 2002. USDA assessed these penalties based on the states high error rate for failing to issue food stamps in an accurate way to low-income families and individuals. However, due to a greatly improved rate and other factors, USDA and California have agreed to a more reasonable penalty amount. The food stamp error rate measures inaccuracies in applying federal and state food stamp rules. The USDA sanctions states with error rates 5% above the national average and provides incentive payments to states considerably below the national average. Californias 2001 error rate was 17.4%, the highest of all states, compared to 8.66% nationally. CDSS estimates that about 80% of the error rate was associated with Los Angeles County. Overpayments accounted for about 70% of inaccurate benefit amounts, while underpayments made up 30% of errors. Although about 1.7 million Californians receive food stamp benefits each month, it is estimated that at least another one million persons are eligible but not receiving benefits, in large part due to programmatic complexity, complicated eligibility procedures, a lack of applicant knowledge about the Food Stamp Program, and social stigma associated with receiving food stamps.b Due to these complexities, efforts to increase participation can increase error rates. California will not be assessed a penalty for FFY 2003 because of improvements in the error rate. Due to new federal legislation, California will not be penalized again unless it is over the tolerance level for two consecutive years.
Information in this section was reviewed by the Food Stamp Branch, California Department of Social Services, on May 27, 2004.
b a

WIC
The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) serves low-income pregnant, postpartum, and breastfeeding women, and children under five years old (including foster children) at nutritional risk. WIC offers special checks (vouchers) to buy specific healthy foods (e.g., milk, cheese, eggs, cereal, juice, dry beans, peanut butter, and infant formula) in grocery stores, and provides nutrition and health education, breastfeeding support, and referrals to health care and other services.

The WIC Success Story

Originating as a pilot project in 1972, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) became a permanent national health and nutrition program by 1974. Since then, numerous studies have demonstrated that pregnant women who participate in the WIC program seek prenatal care earlier and eat a healthier diet, resulting in longer pregnancies, fewer low and very low birthweight babies, and decreased fetal and infant mortality.a Participating in WIC has been shown to decrease low birthweight by up to 25%b and reduce the prevalence of childhood anemia.c WIC has also been shown to be more effective than food stamps or other cash income in improving preschoolers intake of key nutrientsd and has improved rates of childhood immunization and regular medical care.e These successes translate into huge savings in health care dollars. In a report published in 1992, the U.S. General Accounting Office (GAO) reviewed 17 cost-benefit studies and concluded that for every $1.00 spent on WIC, $3.50 was saved. The GAO concluded that if WIC served all eligible pregnant women, an estimated $51 million in federal and state health care funds would be saved.f
Whaley, S., & True, L. (2000). California WIC and Proposition 10: Made for each other. Halfon, N., et al. (Eds.) Los Angeles, CA: University of California, Los Angeles, Center for Healthier Children, Families and Communities.
b a

Hess, D., & Weill, J. (2003, February). State of the states: A profile of food and nutrition programs across the nation. Available from the Food Research and Action Center website, http://www.frac.org

Center on Budget and Policy Priorities. (1994). The research findings on WIC. Washington, DC: Center on Budget and Policy Priorities. Ibid.

c d

Rose, D., et al. (1998). Household participation in the food stamp and WIC programs increases the nutrient intakes of preschool children. Journal of Nutrition, 128, 548555.
e

Rush, D. (1986). The national WIC evaluation: An evaluation of the Special Supplemental Food Program for Women, Infants, and Children. (Vol. 1: Summary). Washington, DC: U.S. Department of Agriculture. California Department of Health Services. About WICdetailed description. Retrieved July 23, 2003 from http://www.wicworks.ca.gov/ about/detailed.html

26

California has the largest WIC program in the nation, accounting for 1.2 million of the 7.5 million low-income, nutritionally at-risk American women, infants, and children served in an average month during 2002.75 The WIC Branch in CDHS administers and allocates funds to 81 local public agencies and private nonprofits that provide services through 650 local sites.76 WIC sites range in size from small neighborhood or rural sites serving fewer than 1,000 participants to large urban area sites serving over 300,000 participants.77 In addition, more than 3,500 grocery stores statewide serve as redemption sites for WIC vouchers. The majority of WIC participants in California are Latino (70%), followed by white (15%), African American (10%), and Asian (1%).78 Some 51% of WIC participants are enrolled in MediCal, though less than 20% participate in the Food Stamp Program, and even fewer are CalWORKS recipients.* About 24% of WIC participants are pregnant or postpartum women, 23% are infants under age one, and 53% are children up to age five.79 WIC is funded entirely by USDA. Unlike the Food Stamp Program, which is an entitlement program that must serve all eligible people, WIC is a discretionary program, meaning that participants are served only when Congress makes funds available. Because it is not a mandatory program, WIC funding is always vulnerable to being cut. In FFY 2002, California received nearly $779 million from USDA for WIC. The national average federal cost of a WIC food package that year was $35 per month, and the average monthly administrative cost per participant, including nutrition risk assessments and nutrition education, was about $13.80 Eligible participants must be at or below 185% of the federal poverty level and be at risk of nutrition-related health problems. The income guidelines for a family of four are $34,040 annually or $2,837 monthly (effective through June 30, 2004).81 Applicants must document their income and provide proof of residency (not immigration status). Because WIC services are limited to funds available, individuals applying for program benefits are served on a highest need basis. Under the WIC-defined priority system, if federal funding is not sufficient, pregnant women and infants with documented health problems are ranked above children with inadequate dietary intake.

Nutrition Education WIC

WIC is one of the few federal nutrition programs that specifically earmarks funding for nutrition education and, in particular, breastfeeding promotion and support. Federal WIC regulations require WIC service providers to offer at least two free nutrition education sessions to participants during the two annual certification periods. While WIC participants are not required to attend classes, local WIC agencies often schedule nutrition education sessions when food benefits are issued, making it convenient for clients to drop in. Education on a variety of health and nutritionrelated topics emphasizing the relationship between proper nutrition and good health is often provided in individual counseling sessions, through group classes, or through films and videos. Peer counselors are increasingly used to promote and support breastfeeding among WIC mothers. Federal funds were appropriated for the first time in FFY 2004 to support WIC Breastfeeding Peer Counseling in all states, including California.

The WIC Farmers Market Nutrition Program, which operates between May and November, provides about 400,000 WIC recipients with one $10 coupon each per year to purchase fresh, locally grown fruits and vegetables from certified farmers markets.82 In many cases, families receive two $10 coupons one for the mother and one for the child if they are both on WIC. To support the WIC Farmers Market Nutrition Program, California has received a $3 million grant from USDA annually for each of the past 3 years.83 The WIC Farmers Market Nutrition Program is an optional program and requires a 30% match using state funds, as well as local donations and state and local in-kind support.84

* Personal communication, February 15, 2004, M. Sharp, Director of the Los Angeles Office, California Food Policy Advocates. The percentages of WIC participants also enrolled in the Food Stamp Program were estimated by the Public Health Foundation.

27

Breastfeeding: The First Line of Defense

Human milk is the first and single most important nutritional substance available for babies. Breastfeeding saves lives, reduces illness, promotes healthy infant development, enhances maternal and infant well-being, and reduces health care costs.a The benefits of breastfeeding can last a lifetime. Breastfed infants are exposed to a wider variety of tastes through breast milk and seem to accept a wider variety of new foods than do formula-fed babies;b and breastfeeding alone can greatly reduce the risk of childhood obesity. Children breastfed at any time are 15% to 25% less likely to become overweight, while children breastfed 6 months or longer are 20% to 40% less likely.c Breastfeeding also lowers future risks for cardiovascular disease and type 1 diabetes.d
American Academy of Pediatrics. (1997, December). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 100(6), 10351039. Sullivan, S. A., & Birch, L .L. (1994). Infant dietary experience and acceptance of solid foods. Pediatrics, 9, 884885.
c b a

Child Nutrition Programs

In 1975, the Legislature established the State Meal Program which requires public school districts and county superintendents to make one free or reduced-price nutritionally adequate meal available to each needy student every school day. The vast majority of districts (all but about 50 out of 1056) meet this requirement through participation in federal programs. The Child Nutrition Programs funded by USDA serve over 4 million meals each day at approximately 48,000 locations throughout California. Programs include the National School Lunch, School Breakfast, Summer Food Service, Special Milk, and Child and Adult Care Food Programs. Through the Food Distribution Program for Schools, USDAs commodities are also provided to the more than 10,000 public and private nonprofit schools in California that provide meals to students. The Child Nutrition Programs are administered by the California Department of Education through its Nutrition Services Division, and by school districts, private schools, child care agencies, and others at the local level. Funds are provided by USDA to state agencies for administrative expenses incurred in supervising and giving technical assistance to schools and other agencies participating in Child Nutrition Programs. Child Nutrition Programs operate on a reimbursement basis, with schools and other agencies paid based on the number of meals served.* Agencies submit a monthly reimbursement claim form to CDE which reviews it, and if appropriate, forwards the form to the State Controllers Office for a check to be issued. The following guidelines are used by schools, child care agencies, and other institutions and facilities that participate in Child Nutrition Programs. Children from households with incomes below 130% of the federal poverty level may receive free meals. Children have automatic eligibility for free meals if they are in Head Start or if their household is enrolled in the Food Stamp Program, the Food Distribution Program on Indian Reservations (FDPIR), or CalWORKs. In addition, children for whom a Kin-GAP** payment is received are also automatically eligible.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Preventing chronic diseases: Investing wisely in health: Preventing obesity and chronic diseases through good nutrition and physical activity. Retrieved on May 26, 2004, from http://www.cdc.gov/nccdphp/pe_factsheets/pe_pa.htm

Davis, M. K. (2001, February). Breastfeeding and chronic disease in childhood and adolescence. Pediatric Clinics of North America, 48(1),12541.

* California has been supplementing the federal reimbursement for free and reduced-price meals since 1974. This augmentation, known as the Moscone Nickel, was $.1343 per meal in 200304. ** The Kinship Guardianship Assistance Payment Program, or Kin-GAP, provides relative caregivers financial assistance if they assume legal guardianship of a foster child.

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 Children living above 130% but below 185% of poverty qualify for reduced-price meals. Children from households with higher incomes may purchase full-price meals at rates set by the school. When a school or other agency in California is part of a federal meal program, all children, regardless of their household income or immigration status, are entitled to a meal, for which the school or other agency receives a federal cash subsidy, and in some instances, agricultural commodities. Depending on the household income, children qualify for a free, reduced-price, or full-price meal. Application forms for free or reduced-price meals are usually provided at the beginning of the school year, when children transfer into a school, or when children enroll for child care.

NATIONAL SCHOOL LUNCH PROGRAM

Established in 1946, the National School Lunch Program (NSLP) is the oldest school food program. NSLP operates in public and private nonprofit schools and residential child care institutions to provide daily nutritionally balanced, low-cost or free lunches. About 88% of California school districts (929 out of 1,056)85,86 participate in the National School Lunch Program. On an average day in FY 2001-02, some 2.5 million school children received free and reduced-price lunches.87 Of the more than one-half billion school lunches served in California during 2001-2002, some 63% were free, 12% were reduced-price, and 25% were full-price meals (Table 5). Under the National School Lunch Act, schools are reimbursed according to the income level of children served. A slightly higher level of reimbursement is paid to schools where more than 60% of students are eligible for free or reduced-price meals.

USDA Nutrition Standards for School Meals

The USDA requires that school lunches and breakfasts be consistent with the recommendations of the most recent Dietary Guidelines for Americans. Lunches must provide at least one-third of the Recommended Dietary Allowances (RDAs) for specific nutrients protein, calcium, iron, vitamin A, and Vitamin C and one-third of calorie needs for specified age or grade groups. School breakfasts must provide at least one-quarter of the RDAs for specific nutrients. USDA allows four menu-planning approaches for healthful and appealing meals. Minimum nutrition standards must:a,b Provide a variety of foods; Limit total fat to 30% of total calories; Limit saturated fat to less than 10% of total calories; Be low in cholesterol; Offer plenty of grain, vegetables, and fruits; and Offer a diet moderate in salt and sodium. National data from the 1998-99 School Nutrition Dietary Assessment Study found a statistically significant trend showing that schools had lowered levels of fat and saturated fat in school meals. However, most schools were not yet meeting the goal of limiting total fat to 30% of total calories. Only about 20% of elementary schools and 14% of secondary schools met the standard for calories from fat, and only 14% of all schools met the standard for saturated fat.c
a b

Personal communication, April 20, 2004, S. B. Foerster, Chief, Cancer Prevention and Nutrition Section, California Department of Health Services.

U.S. Department of Agriculture. Healthy School Meals Resource System: Regulations. Available from the Health School Meals Resource System: Regulations website, http://schoolmeals.nal.usda.gov/Regulations/index.html
c

U.S. Department of Agriculture. (2001, January). School Nutrition Dietary Assessment Study II: Summary of findings. Retrieved March 31, 2004, from http://www.fns.usda.gov/oane/MENU/Published/CNP/FILES/SNDAIIfindsum.htm

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TABLE 5. NATIONAL SCHOOL LUNCH PROGRAM, CALIFORNIA

Total meals served, FY 2001-02 (in millions) Free meals Reduced-price meals Paid meals 319.1 58.2 125.7 Federal reimbursement per meal, FY 2003-04 Schools where less than 60% of Schools where 60% or more students get meals students get meals $2.19 $1.79 $0.21 $2.21 $1.81 $0.23

Sources: California Department of Education. (2002, December). FY 2001-02 County profile for California school nutrition programs, Retrieved May 25, 2004, from http://www.cde.ca.gov/ds/sh/sn/documents/coproschool0102.pdf Food Research and Action Center. The Child Nutrition Programs. Retrieved July 25, 2003 from www.frac.org/pdf/rates.PDF

USDA cash reimbursements are also available both through the National School Lunch Program (NSLP) and the Child and Adult Care Food Program (CACFP) to help schools and after-school care programs serve snacks to children in after-school activities. An after-school program must provide children with regularly scheduled activities in an organized, structured, and supervised environment that can include mentoring or tutoring programs. (Competitive interscholastic sports teams are not an eligible after-school program.) USDA-reimbursed after-school snacks are primarily served in low-income areas where 50% or more of the children are eligible for free and reduced-price school meals.88 Programs must meet local licensing requirements and safety standards.

During FY 2003-04, qualifying California schools and afterschool care programs were reimbursed $0.60 for free snacks, $0.30 for reduced-price snacks, and $0.05 cents for paid snacks.89

SCHOOL BREAKFAST PROGRAM

Established under the Child Nutrition Act of 1966, the School Breakfast Program provides funding for nutritious breakfasts. About 71% of California school districts participate in this program. On an average day during FY 200102, this program served California school children nearly 843,000 school breakfasts. Some 167 million school breakfasts were served in that school year 80% were free, 10% were reduced-price, and 10% were paid meals (Table 6).

TABLE 6. SCHOOL BREAKFAST PROGRAM, CALIFORNIA

Total meals served, FY 2001-02 (in millions) Free meals Reduced-price meals Paid meals 134.6 15.9 16.4 Federal reimbursement per meal, FY 2003-04 Schools where less than 40% of Schools where 40% or more students get free/reduced-price meals students get free/reduced-price meals $1.20 $0.90 $0.22 $1.43 $1.13 $0.22

Sources: California Department of Education. (2002, December). FY 2001-02 County profile for California school nutrition programs, Retrieved May 25, 2004, from http://www.cde.ca.gov/ds/sh/sn/documents/coproschool0102.pdf Food Research and Action Center. The Child Nutrition Programs. Retrieved July 25, 2003 from www.frac.org/pdf/rates.PDF Reich, J. (2004, April). The state of the plate: Demystifying Californias school meal programs. San Francisco, CA: California Food Policy Advocates.

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SUMMER FOOD SERVICE PROGRAM

Created in 1968, the Summer Food Service Program (SFSP) makes funding available to provide meals to children under 18 when they are out of school for 15 or more consecutive school days. The sponsors receive reimbursements from USDA through CDE for the meals they serve based on their documented operating and administrative costs. For calendar year 2004, sponsors were reimbursed for operating costs up to $1.35 for breakfast, $2.35 for lunch or supper, and $0.55 for snacks.90 Administrative costs are also reimbursed at different rates. The SFSP is operated locally by state-approved sponsors, which may be schools, private nonprofit organizations, or units of local, municipal, county, tribal, or state government. Free meals are provided to children at sites such as public or private nonprofit schools, residential and day camps, colleges and universities participating in National Youth Sports Programs, programs serving children of migrant workers, and neighborhoods and schools where at least half of the children are eligible for free or reduced-price meals. On a typical day during FFY 2001, about 811,000 California students participated in Summer Food Service Programs.91

The USDA paid 13 cents in school year 2003-04 for each half-pint of milk sold to children through the Special Milk Program.92 Preliminary data for fiscal year 2003 show a total of 5.2 million half-pints of milk served in California through the Special Milk Program,93 a decrease of over 700,000 from 2002.

CHILD AND ADULT CARE FOOD PROGRAM

The Child and Adult Care Food Program (CACFP) is another Child Nutrition Program funded by the USDA at the federal level and administered by the Nutrition Services Division of CDE, which reimburses local state-approved sponsors on a monthly basis (see Tables 7 and 8). California received $206 million in federal funds for CACFP in 2003. California CACFP sponsors also receive cash in lieu of commodities. CACFP includes child care, adult day care, and emergency shelter components. The CACFP child care component provides funding for meals served in public and private licensed child care centers and day care homes. Sites include Head Start Centers, afterschool programs, and family day care homes. Programs may be reimbursed up to two meals and a snack, or two snacks and a meal per child per day, with higher reimbursements for meals served to children living at or below 185% of poverty. Meals must meet the USDA minimum meal requirements. In California, about 64% of licensed child care centers and family day care homes participate in CACFP. On an average day in 2002, some 135,568 children were served in 22,489 family day care homes, and 161,221 children were served in 4,284 child care centers, including Head Start centers.94,95

SPECIAL MILK PROGRAM

The USDA-funded Special Milk Program provides funding to schools and other agencies to provide milk to children at reduced prices. Eligible agencies are those that do not participate in the National School Lunch or Breakfast Programs, the Child and Adult Care Food Program, or the Summer Food Service Program. Agencies include public and private nonprofit schools, licensed residential child care institutions (e.g., group homes, juvenile halls), nursery schools, child care centers, settlement houses, and summer camps.

TABLE 7. FEDERAL REIMBURSEMENT FOR CACFP MEALS IN CHILD AND ADULT CARE CENTERS, CALIFORNIA, 7/1/03-6/30/04
Free Breakfast Lunch/Supper Snacks $1.20 $2.19 $0.60 Reduced-price $0.90 $1.79 $0.30 Paid $0.22 $0.21 $0.05

Source: Food Research and Action Center. The Child Nutrition Programs. Retrieved July 25, 2003, from http://www.frac.org/pdf/rates.PDF

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TABLE 8. FEDERAL REIMBURSEMENT FOR CACFP MEALS SERVED FAMILY DAY CARE HOMES, CALIFORNIA, 7/1/03-6/30/04
Tier I* Breakfast Lunch/Supper Snacks $0.99 $1.83 $0.54 Tier II** $0.37 $1.10 $0.15

IN

* Tier I day care homes are located in low-income areas, or are homes where the providers household income is at or below 185 percent of the Federal income poverty guidelines. ** Tier II homes are family day care homes that do not meet the location or provider income criteria for a Tier I home. A provider of a Tier II home may have the sponsoring organization identify income-eligible children, so that meals served to those children who qualify for free and reduced-price meals would be reimbursed at the higher Tier I rates. Source: Food Research and Action Center. The Child Nutrition Programs. Retrieved July 25, 2003, from http://www.frac.org/pdf/rates.PDF

The CACFP adult day care component is available to public agencies or private organizations that provide nonresidential day care services to functionally impaired adults or adults who are 60 years of age or older. These centers include adult day care centers, support day care centers, adult day health centers, or approved Alzheimers centers. The program provides supplemental funding to assist centers in providing a quality nutrition program. Each meal or supplement must contain at least the minimum quantities of specified food components (which may differ from those required under the Senior Nutrition Program).96 The CACFP emergency shelter component provides funding to local public or private nonprofit emergency shelters if they provide residential and food service to homeless children and their parents or guardians. Each residential child age 12 years and younger may receive up to three reimbursable meals every day. Children with disabilities, regardless of age, and migrant children age 15 and younger may also receive CACFP meals. Emergency shelters are reimbursed for serving meals and snacks that meet federal nutrition guidelines. Maximum payment rates are based on the number of meals and snacks served at the free rate for child care centers.

home-delivered meal programs described below, the ENP provides low-income seniors with nutrition education, opportunities for socialization to prevent isolation, a meal that provides one-third of the Recommended Dietary Allowance, and nutrition counseling when there is adequate funding. These two federally funded programs target persons with the greatest economic need, although there are no income eligibility requirements for participation. The Senior Farmers' Market Nutrition Program is also a federally supported program, while the Brown Bag Program is state supported.

CONGREGATE NUTRITION SERVICES

The Congregate Nutrition Services of the Elderly Nutrition Program provides a meal in a group setting along with nutrition education, health promotion, and opportunities to socialize. Eligible recipients are 60 years of age and older. All participants are given an opportunity to make a confidential donation for the meal, but no one is turned away due to inability to pay. In California, participant donations and fundraising by ENP providers provide approximately $12 million per year for program operations, allowing the program to serve more seniors than would otherwise be served with government funding only. In California, approximately 131,000 seniors (representing about 3% of the 4,742,499 Californians 60 and older)98 participate in the congregate meal program annually and receive over 9 million meals. In 2003, the state received approximately $23 million in federal funding plus an additional $5.5 million in supplemental funding from the Nutrition Services Incentive Program.*

Older Adult Programs97

The federal Administration on Aging (AoA) provides funding to the California Department of Aging (CDA) for the administration of the Elderly Nutrition Program (ENP). CDA contracts with 33 Area Agencies on Aging to provide ENP services throughout the state utilizing approximately 275 nutrition providers. Through the congregate and

* The U.S. Department of Agriculture (USDA) provides commodities and/or cash in lieu of commodities to provide a supplement for the cost of qualified Elderly Nutrition Program (ENP) meals. When cash is chosen by a state agency or tribal organization, USDA grants the money directly to the federal Administration on Aging (AoA), which then distributes the cash along with other federal funding. This supplemental funding is referred to as the Nutrition Services Incentive Program (NSIP).
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HOME-DELIVERED MEAL SERVICES

Home-Delivered Meal Services provides meals to individuals age 60 and older who are homebound by reason of illness, incapacity, or disability, or who are otherwise isolated. All participants have the opportunity to make a donation for the meal, but no one is denied service due to inability to pay. Donations and fund raising increase Home-Delivered Meal Services funding by almost $10 million annually. In 2003, about 52,000 California seniors (representing about 1% of those 60 and older) received almost 11 million meals. Federal funding was nearly $22 million with an additional $6.5 million from the Nutrition Services Incentive Program.

Food Distribution Programs

Food distribution programs provide commodity foods to local emergency assistance agencies, disaster relief organizations, and low-income households. Programs include the Emergency Food Assistance Program, the Commodity Supplemental Food Program, the Food Distribution Program on Indian Reservations, and Food Distribution Disaster Assistance.

THE EMERGENCY FOOD ASSISTANCE PROGRAM

Under the Emergency Food Assistance Program (TEFAP), the USDA makes commodity foods available to State Distributing Agencies. At the state level, the Emergency Food Assistance Program at the California Department of Social Services provides the food directly to 50 local food banks. Most are private nonprofit organizations with the exception of five food banks that are county operated. California food banks annually distribute 60 million pounds of USDA commodities and California produce (fresh and processed) to about 1,600 recipient agencies, with networks of soup kitchens and food pantries that serve over 1 million individuals.102 These organizations also distribute commodities to eligible households or use them to prepare and serve meals in congregate settings. In addition, over 160 soup kitchens (sometimes referred to as congregate meal agencies) throughout California serve meals to 35,000 homeless people daily. Eligibility is based upon household income. Households with an income less than 130% of the federal poverty level are eligible to receive emergency food.

SENIOR FARMERS MARKET NUTRITION PROGRAM

The USDA Senior Farmers Market Nutrition Program awards grants to states and tribal organizations for programs that provide fresh fruits, vegetables, and herbs to seniors. In California, low-income seniors receive coupons worth $20 per year to exchange for fresh produce at certified farmers markets. Area Agencies on Aging distribute coupons to low-income seniors through the Elderly Nutrition Program and Brown Bag Program. In 2001, California received a $1 million federal grant for the Senior Farmers Market Nutrition Program, which issued coupons to over 50,000 seniors statewide.99 The California Department of Aging funds and administers the program, which was awarded another $1 million in 2002, and $791,800 in 2003,100 well below the $2 million requested. Funding is available to serve only 8% of Californias low-income seniors.

BROWN BAG PROGRAM

The state-funded Brown Bag Program provides surplus and donated edible fruits, vegetables, and other food products to about 35,000 low-income individuals 60 years of age and older every month at over 300 community sites. Established in 1981, the program is currently authorized under the Older Californians Act of 1980. The Area Agencies on Aging contract with local organizations to obtain and distribute food to eligible participants who receive a bag of groceries (about 18 pounds of food) once or twice a month. These foods are obtained at minimal cost from farmers, food manufacturers, grocery stores, and food banks. The Brown Bag Program serves older adults whose income is not higher than 100% of the California State Supplementary Program (SSP) for a blind recipient. If a surplus of food exists, the program may also provide these services to persons 60 and older with an income up to 125% of the SSP rate for the blind.101 The annual cost to the state is $865,000.

Wasted Food
The USDA estimates that over one-fourth of all the food produced in the United States is wasted. Nearly 100 billion pounds of safe, edible food meat and poultry, fruits and vegetables, milk and eggs are thrown away every year by retailers, restaurants, and farmers. If just 25% of that food were recovered, 20 million additional people could be fed.
Source: U.S. Department of Agriculture. More than one-fourth of U.S. food wasted, USDA study finds. (News Release No. 0212.97). Retrieved July 23, 2003, from www.usda.gov/news/releases/1997/06/0212

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COMMODITY SUPPLEMENTAL FOOD PROGRAM

The Commodity Supplemental Food Program (CSFP) provides food packages and administrative funds to states for low-income adults age 60 and older, pregnant and breastfeeding women, postpartum mothers for up to one year, infants, and children under age 7. Seniors (who make up the vast majority of the California caseload) must have incomes at or below 130% of the poverty level, and women, infants, and children must have incomes at or below 185% of the poverty level or be participating in another qualifying program, such as Food Stamps. Eligibility may also be based on nutritional risk. Risk assessment is based on a variety of measures, including blood tests and height and weight measurements. While serving much the same population as WIC, eligible persons may participate in only one program at a time. At the state level, CSFP is administered by the California Department of Education. CDE provides oversight and funding, and stores and distributes the USDA commodity items to local public and nonprofit food banks. In 2004, California received $2.8 million that funds six CSFP programs based in Los Angeles, Orange, San Francisco, Stanislaus, San Diego, and Sonoma Counties which, combined, served over 57,000 participants per month103 in 12 counties. Food banks in these counties distribute food boxes each month at community sites.

Nonprofit Emergency Food Network

Despite the publicly funded food assistance programs in place, many Californians are still hungry. A vast system of food banks, food pantries, and soup kitchens providing vital links in non-disaster emergency food assistance are found in every county and virtually every community in California to assist local residents needing food. Food banks solicit, receive, inventory, store, and distribute donated food and grocery products to charitable agencies that provide direct services to clients through food programs. Emergency food pantries or closets distribute non-prepared foods and other grocery products to clients who prepare and use these items where they live. Emergency soup kitchens serve prepared meals on-site to clients who do not reside on the premises. Emergency shelters provide shelter services and serve one or more meals each day on a short-term basis to low-income clients in need. The statewide network of approximately 60 food banks distributes over 200 million pounds of food to 5,000 community-based agencies each year. Eleven California counties have more than one food bank, while several rural counties rely on a food bank in another county. Food banks participate in and receive food from large food assistance programs, including the federal Emergency Food Assistance Program (TEFAP), described in this section, and Americas Second Harvest network (the nations largest organization of emergency food providers). About 50 California food banks participate in TEFAP, and about 20 food banks belong to Americas Second Harvest.
Source: California Association of Food Banks. Food banks in California. Retrieved on August 16, 2003, from http://www.cafoodbanks.org/serve.pdf

FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS

The USDA Food and Nutrition Service administers the Food Distribution Program on Indian Reservations (FDPIR) at the federal level and contracts directly with tribal organizations at the state level. FDPIR is administered by seven Indian Tribal Organizations (ITOs) throughout California that, in 2002, served 7,817 persons104 from 64 tribes.105 Nationally, $78.5 million was appropriated for FDPIR in 2002.106 FDPIR provides commodity foods to low-income Indian and non-Indian households that reside on reservations and to Indian families that live in designated areas near reservations. Households are certified based on income and resource standards set by the federal government and must be re-certified at least every 12 months. This program is an alternative to the Food Stamp Program for Indian Tribal Organizations preferring food distribution. Households may not participate in FDPIR and the Food Stamp Program in the same month.

FOOD DISTRIBUTION DISASTER ASSISTANCE

As part of the Federal Emergency Response Plan, the Food and Nutrition Services Food Distribution Division in the USDA is responsible for supplying food to disaster relief organizations, such as the Red Cross and the Salvation Army, for mass feeding or household distribution. At the state level, disaster relief organizations request food and nutrition assistance through the California Food Distribution Program in the Department of Education. Following a disaster, such as an earthquake or flood, this program assists by providing commodity foods to shelters and other mass feeding sites, distributing commodity food packages directly to households in need, and issuing emergency food stamps.

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Foodlink
Foodlink was founded in 1992 as a nonprofit organization through a public/private partnership with the Office of Emergency Services in the California Department of Social Services. Its mission is to channel government commodities from the federal Emergency Food Assistance Program (TEFAP) to rural emergency feeding agencies throughout California, as well as to develop additional food resources. Foodlink works with agriculture and food industries to develop major, ongoing food donation programs distributing fresh and packaged food to the 1.5 million hungry Californians served by Foodlink each month. Foodlink distributes over 35 million pounds of food annually, serving all 58 counties in California through 50 food banks and 1,500 food closets. Foodlinks Donate Dont Dump program salvages food that was previously plowed under, sent to landfills, or sold as feed despite being edible and fit for human consumption. This program alone brought in over 17.7 million pounds of food in 2000. Complementing its anti-hunger efforts, Foodlink obtained over 540,000 square feet of surplus military property in Sacramento in 1994. This has been turned into a job-training facility partnering with major businesses and corporations needing warehousing, trucking, and light equipment repair services. Foodlink puts former welfare recipients and the homeless, hungry, and chronically unemployed to work and is now generating nearly 45% of its $3.8 million annual budget to support its free distribution of food throughout the state.
Source: Foodlink website, http:// www.foodlink.org

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COMMUNITY FOOD SECURITY

What is CFS?
While having a safety net such as WIC and Food Stamps is an important aspect of combating food insecurity, community food security advocates are working to develop and implement strategies that will increase long-term self-sufficiency and capacity in low-income communities. Community food security advocates aim to: Develop community food resources, such as supermarkets and farmers markets, Build self-reliance among residents rather than dependency on outside sources, Protect local agriculture, Collaborate with multiple agencies to develop comprehensive food systems, and Meet the food needs of low-income people.107 Community food security (CFS) can be viewed as a continuum where the goal is to move from less food secure to more food secure through partnerships among communitybased institutions, schools, health professionals, local government, and residents. A key aspect of CFS is to protect and promote local family-based agriculture through community-supported arrangements that build partnerships.108 Strategies to improve CFS include increasing the number of supermarkets in low-income neighborhoods and expanding the number of farmers' markets and farm-toschool programs. 52% of residents from 15 low-income communities in Alameda, Contra Costa, and Santa Clara Counties live within a half mile of a supermarket, leaving over 200,000 people in those communities without walking access to a supermarket.111 Residents dependent on public transportation and living in neighborhoods that lack supermarkets often find it difficult to travel outside of their area to shop for fresh produce and other healthy foods. The combination of supermarkets leaving low-income communities and inadequate transportation has created opportunities in neighborhoods where it may not be feasible to have a supermarket. Some strategies include converting existing corner stores into neighborhood grocery markets that sell healthy foods, and facilitating collaborations between supermarkets and corner stores or farmers/growers and corner stores.112

FARMERS MARKETS
Launched by the California Department of Food and Agriculture in the late 1970s, the Certified Farmers Market Program helps small farmers sell their produce locally by exempting them from strict size, shape, and packing regulations. Today, more than 4,000 farmers at 416 certified farmers markets serve millions of Californians.113 Those served include thousands of low-income consumers who use food stamps and coupons from the WIC Farmers Market Nutrition Program and the Senior Farmers Market Nutrition Program.

SUPERMARKETS AND CORNER GROCERY STORES

Supermarket chains began to abandon inner cities in the 1960s and 1970s as middle- and high-income populations moved to the suburbs.109 Many inner-city neighborhoods must now depend on corner grocery stores that carry alcohol, cigarettes, and mostly nonperishable packaged and convenience foods and a limited selection or no fresh meats, dairy products, and produce. Today, up to three times as many supermarkets per capita are found in middleand upper-income Los Angeles neighborhoods as in lowincome communities.110 In addition, predominately white Los Angeles neighborhoods have over three times as many supermarkets as predominantly African American areas, and about two-thirds more than in Latino communities. In Northern California, a recent study reported that only

FARM-TO-SCHOOL PROGRAMS
Farm-to-school programs encourage school food service programs to purchase more fresh produce from local farmers, and thus provide healthier school meals. Programs facilitate partnerships among health, nutrition, food, school, and farmer/agriculture organizations. Several school districts in California have farm-to-school programs, including Santa Monica, Los Angeles, Ventura, Davis, and Berkeley.114 Strategies to improve CFS include increasing the number of supermarkets in low-income neighborhoods and expanding the number of farmers' markets and farm-to-school programs.

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KEY POLICY ISSUES

Despite Californias many resources, too many residents still experience hunger and food insecurity, and too many are overweight or obese. To address these complex public health challenges, policymakers are wrestling with a number of policy issues to combat obesity and promote healthy eating and to ensure that government programs are coordinated and maximize available resources.

In the last 30 years, portion sizes have increased in every conceivable venue from servings in national restaurant chains, to recipes in cookbooks, to the diameters of cup holders in automobiles.

Combating Obesity and Promoting Healthy Eating

Assigning responsibility for the countrys obesity epidemic is receiving increased attention. Some public health advocates claim food industry labeling and marketing practices are major contributing factors, while industry advocates insist that those who overeat should blame only themselves. Policymakers and advocates are addressing a number of factors that could help reverse obesity trends and promote practices to make healthy eating and physical activity more accessible and appealing.

Congressional legislation Menu Education and Labeling (MEAL) introduced in November 2003 would require nutrition information to be displayed on menu boards and on printed menus at some restaurants and vending machines.117 The Food and Drug Administration (FDA) is calling on food manufacturers and chain restaurants to label food more clearly and is considering stricter labeling requirements for packaged food.118 In 2003, legislation was introduced in six states, including California, requiring availability of nutrition information in fast food chain restaurants.119 In March 2004, the FDAs Obesity Working Group issued a report that included a number of recommendations to reduce obesity.120 One recommendation calls for food labels to display calorie counts more prominently while another calls for developing a consumer education campaign to inform the public that weight control is mainly due to caloric balance. Other recommendations include encouraging restaurants to provide nutrition information to consumers, increasing enforcement for food label accuracy, increasing enforcement against products having misleading or false claims, and working cooperatively with other public, nonprofit, and private entities on obesity research.

MENU AND PRODUCT LABELING

In the last 30 years, portion sizes have increased in every conceivable venue from servings in national restaurant chains, to recipes in cookbooks, to the diameters of cup holders in automobiles. A recent lawsuit charged McDonalds with failing to adequately disclose ingredients in some of its foods, ingredients that trigger possible negative health effects, including obesity. While this lawsuit was dismissed, it generated considerable publicity.115 McDonalds has since announced it will phase out its super-sized fries and drinks by 2005.116 Meanwhile, on March 10, 2004, the U.S. House of Representatives passed new legislation the Personal Responsibility in Food Consumption Act (as yet to go to the Senate), protecting the food industry from lawsuits that blame the industry for the increase in overweight Americans. At the same time, a number of proposals are under consideration to provide consumers with improved nutrition information:

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Super-sized Servings
A 2002 study that compared portion sizes of commonly eaten convenience foods with what was typically offered at the time the foods were first introduced discovered that current portions consistently exceeded those offered in the past and were 2 to 8 times larger than recommended serving sizes.a Another study found that between 1977 and 1996, food portion sizes increased both inside and outside the home for all food categories except pizza, with the largest portion sizes consumed at fast food establishments, the smallest at other restaurants.b During that 20-year period, hamburgers increased by 23%, an order of Mexican food grew by 27%, soft drinks grew by 52%, and snacks, whether potato chips, pretzels, or crackers, swelled by 60%. Super-sizing the option offered at many fast food establishments to upgrade from a large order of fries or a soda to an even bigger one both entices consumers to frequent a place where less money buys an extra large meal and encourages people to eat more. While offering larger portions only increases the price a moderate amount, the real price of larger portions is higher calories, fat, and eventually, weight.c
a

Television ads in particular aim to market non-nutritious foods to children. Half of the ads seen during childrens television shows mainly weekday afternoon and Saturday morning programs are for food,123 and 25% of ads aired during prime-time television viewed by 2- to 11-year-olds are for foods and beverages.124 An analysis of Saturday morning childrens television found that over 40% of the advertised foods were in the fats, oils, and sweets tip of the USDA Food Guide Pyramid. Another 43% of ads were for foods in the grains group, but over 60% of those were for high-sugar cereal. None of the ads promoted fruits or vegetables.125 In the absence of a well-funded, well-coordinated national effort to promote healthy eating to children, the fast food and advertising industries are clearly dominating the nutrition messages sent to children. The $2.7 billion that was spent by the food industry in 2000 to advertise fast food, candy, soft drinks, and other non-nutritional food products far outweighed the $47.5 million in federal funds spent by CDC, USDA, and NCI.* A number of actions are under discussion to help children and adults make wise food choices, including regulating the advertising of unhealthy food products and beverages that target children (similar to regulations that successfully eliminated marketing tobacco products to children). Some have also called for the development of guidelines for responsible marketing of food to children, while others advocate that government and the nonprofit sector should not forge partnerships with companies that market unhealthy products.126 The American Public Health Association gave these issues a big boost in January 2004. The group adopted a resolution that called for food advertisements to be removed from schools and policies to be adopted that promote healthier school food environments.127

Young, L. R., & Nestle, M. (2002, February). The contribution of expanding portion sizes to the U.S. obesity epidemic. American Journal of Public Health, 92(2), 246249.

b Nielsen, S. J., & Popkin, B. M. (2003, January 229). Patterns and trends in food portion sizes, 19771998. Journal of the American Medical Association, 289(4), 450453.

National Alliance for Nutrition and Activity. (2002, June). From wallet to waistline: The hidden costs of super sizing. Retrieved April 21, 2004, from http://www.cspinet.org/new/pdf/final_price_study.pdf

MARKETING JUNK FOOD

Food and soft drink companies are increasingly introducing intrusive and aggressive marketing practices designed to directly influence the food choices that Americans make. Nearly all advertisements spotlight foods low in nutrition, such as convenience food, candy, snack foods, and soft drinks, with just 2.2% $159 million out of the $7 billion spent on food advertising spent to promote fruits, vegetables, beans, or grains.121 Particularly blatant is advertising that bypasses parents and targets children nearly everywhere they are in the course of a day122 television, websites, billboards, vending machines, movies with name brand products, store displays, books, clothing, and school.

An analysis of Saturday morning childrens television found that over 40% of the advertised foods were in the fats, oils, and sweets tip of the USDA Food Guide Pyramid.

* The $47.5 million includes $34 million from the CDC Division of Nutrition and Physical Activitys FFY 2003 budget, $10 million spent by USDA on school-based nutrition education for children through the Team Nutrition program in FFY 2003, and $3.5 million from the National Cancer Institutes (NCI) 5 A Day Programs FY 2003 communications budget.
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SCHOOL ENVIRONMENT
Federally subsidized school meal programs are required to comply with established nutrition standards and dietary guidelines. USDA standards, however, do not apply to food products, called competitive foods, sold outside of the national lunch and breakfast programs. Competitive foods, which are sold in campus snack bars, stores, and vending machines on elementary, middle, and high school campuses not only compete with school breakfast and lunch meals, but typically have minimal nutritional value and tend to be high in sugar, fat, and calories.128 Over two thirds (71%) of schools responding to the 2000 California High School Fast Food Survey129 reported that a la carte items (e.g., pizza, French fries, hamburgers, chips, ` cookies, ice cream and sodas) made up 70% of all school food sales. Half the schools reported carrying foods from brand names, including Taco Bell, Subway, or Dominos. Given this environment, it is not surprising that 25% of 9- to 11-year old respondents in the 1999 CalCHEEPS survey130 and 28% of 12- to 17-year-old respondents to the 2000 CalTEENS survey131 report eating fast food on any given day. California lawmakers are attempting to limit the nutritionally unhealthy food choices that compete with school meal programs. SB 677, signed into law in 2003 and effective July 1, 2004, eliminates sodas from elementary schools, restricts their sale in middle schools, and sets standards for all beverages sold in these schools. Previous legislation, SB 19, passed in 2002, creates new nutrition standards for snack foods (competitive foods and a la carte foods), but ` will only go into effect when the state budget includes a 10-cent per meal increase in funding per reimbursable school meal. This increased reimbursement was not included in the state budgets for FY 2003-04 or FY 2004-05. Strategies to increase the availability of nutritious foods in school include improving already nutritionally sound USDA meals to attract more students and improving or eliminating the nutrition value of competitive foods.

Specific proposals under discussion include:132 Establishing nutrition standards (similar to those in SB 19) for all competitive foods sold at K-12 public school campuses and for foods sold at state subsidized day care, preschools, after-school programs, Head Start programs, and state-supported community centers, parks and recreation facilities; Eliminating marketing of high-calorie, low-nutrition foods and beverages to elementary and secondary school children, including marketing in educational materials; and Requiring that all foods sold or used in school fundraising both on and off campus meet the nutrition standards set in SB 19.

Sustaining School Cafeterias

Federal reimbursements are insufficient to fully fund school meals. In a 2000 survey of 10 public school districts in California, federal reimbursements supported only 30% to 80% of the food service budgets.a This budgetary pressure causes many schools to offer students less nutritious foods. Many schools generate additional revenue from vending machines that can produce up to 12% of their overall food service budget. A number of schools also have lucrative contracts with beverage companies that guarantee funds during the states current budget crisis. When competitive foods are sold by PTAs or student organizations, they draw resources away from the school food service units that may be struggling just to make ends meet.b
a

Craypo, L., & Samuels, S. (2001, January). California school food finance study: Key findings. Retrieved January 24, 2004, from http://www.cfpa.net/obesity/FSFinanceSurvey.pdf Reich, J., et al. (2003, April). Improving meal quality in Californias schools: A best practices guide for healthy school food service. (Revised). Retrieved January 20, 2004, from http://www.cfpa.net/obesity/ MealQualityReport_May2003.pdf

USDA standards, however, do not apply to food products, called competitive foods, sold outside of the national lunch and breakfast programs.

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Schools Restrict the Availability of Competitive Foods

Some California school districts, including Oakland, Los Angeles and San Francisco, as well as individual schools, such as San Diegos Vista High School, have established new policies that ban or limit the sale of low-nutrition foods on campus.

Oakland
Effective February 2002, the Oakland Unified School District completely banned the sale of sodas, drinks that contain caffeine or a high concentration of sugar, candy, and similar products. This ban was the first of its kind in California and among the strictest in the country.

Los Angeles
In January 2004, the Los Angeles Unified School District (LAUSD) banned soft drinks on its 677 campuses during school hours. In July 2004, nutrition standards were implemented for all foods sold on all campuses in LAUSD.

San Francisco
Effective at the beginning of the 2003-04 school year, the San Francisco Unified School District banned sodas and unhealthy snacks from school cafeterias.

San Diego
Vista High School banned junk food vending machines and purchased its own vending machines to provide its 3,500 students with healthy alternatives, including yogurt, fruit, vegetable plates, bagels, and salads. Sodas remain available, but cost more than water, juice, and milk. In the first year of operation, sales from vending machines produced $187,000, and the high school made $15,000 in commission, $6,000 more than it had made under the previous contracts with soda companies.
Sources: California Food Policy Advocates. Food quality and obesity: Local action. Available from the California Food Policy Advocates website, http://www.cfpa.net/ L.A. schools ban sodas. (2002, August 27). Reuters. Retrieved May 27, 2004, from http://cnnstudentnews.cnn.com/2002/fyi/teachers.ednews/08/27/la.soda.reut/ LaFee, S. Healthy choices, healthy budgets: California schools find ways to bolster the lunch line bottom line. (2003, Summer). California Schools. Retrieved May 27, 2004, from http://www.csba.org/csmag/Summer2003/csMagStoryTemplate.cfm?id=21

Federal Report Calls for Improved Nutrition Education

The United States General Accounting Office (GAO) released a major report in April 2004 entitled Nutrition Education: USDA Provides Services Through Multiple Programs, but Stronger Linkages Among Efforts Are Needed. The GAO recommends that the Secretary of Agriculture develop a unifying strategy for USDAs nutrition efforts that: (1) identifies ways to improve coordination efforts and strengthen the linkages among the nutrition education efforts, and (2) explores options to improve program monitoring and evaluation by collecting reliable data on services and recipients, identifying and disseminating lessons learned, and considering a longer-term evaluation strategy.
Source: U.S. General Accounting Office. (2004, April). Nutrition education: USDA provides services through multiple programs, but stronger linkages among efforts are needed. (A report to the Committee on Agriculture, Nutrition, and Forestry.) Retrieved May 26, 2004, from http://www.gao.gov/new.items/d04528.pdf
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NUTRITION EDUCATION AT SCHOOL

There is no consistent or comprehensive approach for nutrition education in California. While nutrition education is funded as a key component of the WIC program and as a state option for reimbursement through the Food Stamp Program when matching funds are identified, nutrition education is not a funded component for child nutrition programs. Until the early 1990s, nutrition education for children participating in school- and community-based child nutrition programs and training of educational and food service personnel were subsidized in part through grants to state agencies from the USDA Nutrition Education and Training (NET) Program. Authorized at $.50 per child, the program has not been funded since the late 1990s. In 1995, the Team Nutrition (TN) Training Grants program was established. Through a competitive application process, TN provides limited funds to state agencies that administer school meal programs to train and provide technical assistance to food service staff and some nutrition education for children and parents. In 2003, only $4 million was

Food Stamp Nutrition Education New Proposals

Currently, state Food Stamp Programs may receive federal reimbursements for nutrition education targeted to Food Stamp recipients and potentially eligible low-income individuals. However, in May 2004, the USDA proposed to limit Food Stamp Nutrition Education to Food Stamp recipients only. If implemented, the new policy framework would cut the number of Californians that could be served from 10 million low-income persons to 1.7 million Food Stamp users and limit the number of education sites from the nearly 4,000 involved in the California Nutrition Network to the 350 Food Stamp offices and an uncertain number of other locations where food stamp recipients congregate. Should the proposals be adopted, reimbursable nutrition education activities would no longer include many of the broad-based public health and social marketing approaches recommended by the recent GAO report (see page 40) as the most effective and cost-efficient means to achieve large-scale changes in health behavior.
Source: Personal communication, August 23, 2004, S. B. Foerster, Chief, Cancer Prevention and Nutrition Section, California Department of Health Services.

15-year-olds, to just over 50% of 16- and 17-year-olds.135 It is thus not surprising that only 25% of California students meet minimal fitness standards.136 A number of proposals are under discussion to better utilize PE and physical activity to fight obesity in children, including: Promoting the use of schools as community centers so that children, youth, and their families have a place to be physically active before, during, and after school, as well as on weekends;137 Enforcing state law that mandates minimum PE requirements for grades 1 through 12;138 Assessing the quality and quantity of PE classes being taught in K-12 public schools;139 and Requiring school in-service funds to further train PE teachers.140 In addition, innovative programs are being tried in some California schools and throughout the country where the traditional PE emphasis on team sports or competitive games has been replaced with a focus on developing knowledge and skills that lead to developing lifelong fitness habits.141 The new wellness-based PE includes aerobics, running, walking, and yoga. Although statewide standards for the new PE were developed during the 1990s, the California State Board of Education has yet to approve them.142

authorized nationally for school food service training grants and demonstration projects, with a maximum of $200,000 awarded to any one state per year.133 California distributes its $200,000 Team Nutrition funds through a mini-grant process to school districts. Limited funding for nutrition education has consequences. There is no required component of the California K-12 school curriculum focused on nutrition education, and there are no nutrition education training requirements for either the educators who teach nutrition or the child nutrition staff working in food programs. More positively, over 450 school districts are participating in the California Nutrition Network and providing a range of nutrition education interventions at about 1,850 low-resource school sites.134

WORKSITE HEALTH PROMOTION

Given rising rates and costs of overweight and obesity, policymakers, employers, unions, and employees are recognizing the value of promoting healthy eating and physical activity practices at work. Leaders in both the public and private sectors have formulated a number of approaches to offer employees an environment that supports healthy eating and physical activity, and they emphasize the importance of reaching low-wage workers as well as professional employees who may have greater opportunity to flex their time and control their environments. Advocates also emphasize the importance of the state becoming a model employer by establishing a healthy worksite infrastructure and policies for employees, partners, and contractors. Employers, large and small, public and private, are encouraged to assess their workplaces,* increase access to healthy foods, increase options for physical activity, and create an environment that supports employees making healthy lifestyle decisions.143

PHYSICAL EDUCATION
Physical education (PE) can be an opportunity to instill in children life-long physical fitness values. State law mandates physical education requirements for all students, yet many schools do not meet those requirements, and many students do not take PE. Teen respondents to the 2000 CalTEENS survey revealed a decline in PE enrollment from over 90% of 12- and 13-year-olds, to about 80% among 14- and

* For an example of one assessment tool, see Check for Health: Workplace Environmental Assessment at http://ca5aday.netcomsus.com/common/file.php/pg/ dodo/cafiveaday/binaries/99/DHS.Worksite.audit.tool.pdf
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Public policymakers can support worksite health promotion by establishing: Liability waivers to protect employers that offer physical activity facilities and programs; Healthy eating food service policies in public buildings; Construction standards for public buildings that support physical activity; and Pre-tax options to employees to pay for health and wellness programs.144

Worksite Activities to Improve Employee Health

In order to improve access to healthy foods at workplaces, employers can provide healthy foods at meetings and in vending machines, offer healthy options for potlucks and other special occasions, work with vendors and restaurants near the worksite to offer more healthy choices, and establish farmers markets at the worksite or in collaboration with neighboring worksites. In order to improve access to physical activity at workplaces, employers can encourage walking at breaks and lunch times, provide space or facilities at the workplace, ensure that stairways are accessible and safe, and provide facilities that support commute modes such as bicycling and walking.
Source: Backman, D. R., Carman, J. S., & Aldana, S. G. (2004, January). Fruits and vegetables and physical activity at the worksite: Business leaders and working women speak out on access and environment. California Department of Health Services & the Public Health Institute. Retrieved April 29, 2004 from http://www.phi.org/pdf-library/dhs-worksite.pdf

Many land use and transportation policies at both the state and local levels encourage development of sprawling communities and foster dependence on automobiles.145 Americans currently drive twice the number of miles they did in 1963,146 with walking and cycling making up less than one-tenth of all urban trips in American cities.147 Research shows that Americans living in automobiledependent, sprawling counties are less likely to walk and more likely to be overweight or obese, and have higher rates of hypertension than those living in less spread-out counties.148 Californias transportation infrastructure presents significant barriers to residents who do not own or drive a car or who live in low-income neighborhoods without supermarkets or other sources of fresh produce.149 A host of community design and transportation policies can support physical activity and promote better health.150,151,152 A sampling of these measures includes: Requiring sidewalks and other pedestrian aids in sprawling communities; Slowing traffic with street narrowing, traffic circles, or speed bumps; Instituting programs to make it safe for children to walk and bike to school; Establishing bike paths and park trails that are safe and accessible; Expanding public transportation; Revitalizing or developing walkable neighborhoods; Pursuing jobs/housing balance and mixed use development (housing/retail/office) to increase the number of residents who can walk to work and to decrease the number and duration of commutes; Promoting joint use planning so that parks and schools are sited adjacent to one another and share facility and maintenance costs; Creating city/county pedestrian and bicycle general plans; Supporting and marketing farmers markets; Limiting permits and land use designations for liquor stores and convenience stores; and Preserving agricultural land.

COMMUNITY DESIGN AND TRANSPORTATION PLANNING

Despite two decades of expert recommendations encouraging better eating habits and more physical activity, the vast majority of Americans are overweight and sedentary. Policymakers, planners, and public health officials are increasing their focus on how community design and transportation policies can support, and not restrict, physical activity and nutritious diets.

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Effective Governance
Federal, state, and local governments are all working to strengthen the programs intended to alleviate food insecurity and promote healthy eating and physical activity. Some of the major efforts focus on the role of government in dealing with underutilized federal food programs, untapped federal resources, and insufficient program coordination.

Increasing Food Stamp Program Utilization

In the past few years, a number of barriers to the FSP have been reduced or eliminated in California. These include: Reducing the lengthy application process. The complicated Food Stamp application was simplified and shortened in the fall of 2000. Ending monthly reporting requirements. Californians used to lose food stamp benefits if they did not turn in a monthly income and resources report. The monthly requirement has been changed to quarterly reports, effective in June 2004. (Nationally, states are moving to semi-annual reporting.*) Electronic Benefits Transfer (EBT). This new system provides food stamps through an electronic card that can be used at certified grocery stores, supermarkets, and farmers markets. This approach removes much of the stigma associated with public assistance. Accounting for increased energy costs. In 2001, the Department of Social Services raised the standard utility allowance and increased food stamp benefits by about $11 a month for over 300,000 households to reduce the impact of Californias energy crisis on food stamp recipients. Eliminating cap on car value. State law effective January 2004 allows a food stamp recipient to own a reliable car to get to work by exempting the value of all vehicles when determining eligibility for the Food Stamp Program. Providing transitional food stamp benefits. State law effective January 2004 provides funding for five months of transitional food stamp benefits for families leaving CalWORKs.
*Personal communication, April 20, 2004, S. B. Foerster, Chief, Cancer Prevention and Nutrition Section, California Department of Health Services. Source: California Food Policy Advocates. (2003). Knocking down barriers to food assistance: A short progress report for California. Available from the California Food Policy Advocates website, http://www.cfpa.net

UNDERUTILIZED FEDERAL FOOD PROGRAMS

Despite continuing hunger and food insecurity, federal food assistance programs remain underutilized in California due to a number of barriers. One way to end food insecurity and improve dietary quality is to help families access all the nutrition programs for which they are eligible.

Food Stamp Program

FSP is the largest and most comprehensive component of the hunger prevention safety net, yet over a million Californians potentially eligible to participate in FSP do not. According to USDA statistics, in 2001, only 54% of the 3 million Californians eligible for food stamps received benefits.153 In 2001 and 2002, the state was sanctioned by USDA for high error rates in issuing food stamps inaccurately (see sidebar on page 26). While California has one of the lowest participation rates among all 50 states, preliminary data show a modest 6.8% increase in participation from 2001 to 2003.154 Food stamp advocates and analysts have called for increased outreach an optional state administrative activity to improve FSP utilization rates and bring more federal dollars flowing into Californias low-income communities. Possible outreach activities include use of local media to inform potential participants about the FSP program and eligibility requirements, as well as better outreach to participants in other public economic assistance programs, such as MediCal.

Despite continuing hunger and food insecurity, federal food assistance programs remain underutilized in California due to a number of barriers. One way to end food insecurity and improve dietary quality is to help families access all the nutrition programs for which they are eligible.

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A number of advocates have called for extending hours at Food Stamp offices, out-stationing eligibility workers to make them more accessible to working families, and using new technology to screen or speed up applications. Others recommend discontinuing the expensive finger-imaging requirement that not only deters some potential Food Stamp participants from applying, but also has been found, according to one state audit, to be ineffective in detecting and deterring fraud.155 Others call for increasing utilization by increasing benefits, especially for seniors.

Eliminating Barriers to Increase Participation in School and Summer Meal Programs

Three federal programs under the National School Lunch Act can help California schools and other childrens meal providers eliminate barriers to student participation in lunch and breakfast programs. The Direct Certification process allows school districts to automatically certify for free meals the children whose families receive benefits under TANF, CalWORKs, the Food Stamp Program, or the Food Distribution Program on Indian Reservations. Provisions 2 and 3 give low-resource schools the chance to streamline their federal meal programs by offering free meals to all students regardless of family income, thus reducing administrative paperwork and costs for the school and increasing student participation A new Seamless Summer Feeding Waiver allows schools to serve meals to children at community or school sites when school is not in session.a Unfortunately, very few school districts use these options. To date: Direct Certification is used by 27% of Californias 1,056 school districts.b Provision 2 is used by only 8% (82) of school districts at 835 sites.c Provision 3 is used by only 2% (23) of school districts at 101 sites.d The Seamless Summer Feeding Waiver was used by only 146 school districts at 954 sites in 2003.e
a

School Meal Programs

Of California schools that enroll more than 20% lowincome children and offer USDA lunches, 425 still do not participate in the School Breakfast Program.156 On a typical day in public schools that do serve meals, only 15% of children have a school breakfast and only 41% of children have a school lunch.157 Further, only 39% of students who received free or reduced-price lunches during the 2002-2003 school year also received free lunches through the Summer Food Service Program.158 A number of proposals are being discussed to increase participation in school meal programs, including: Streamlining the school meal eligibility process by eliminating separate eligibility screenings for different programs through direct certification (see sidebar); Increasing meal reimbursement rates to make it more feasible for schools to provide fresher meals with better nutrition content and improved taste; Establishing new breakfast programs in more schools; Having breakfast available in individual classrooms, which has been shown to increase participation;159 and Eliminating competitive foods that pull older youth away from nutritious meal programs.

Personal communication, May 20, 2004, C. Brown, Special Assistant to the Director, Nutrition Services Division, California Department of Education.

WIC
WIC is not an entitlement program, but depends on annual Congressional appropriations to meet projected needs in the states. When increased funds become available, state and local WIC providers can enroll more participants. When funding is cut, or need or food costs rise, enrollment must be curtailed. The federal Office of Management and Budget estimates that five-year spending caps on all domestic discretionary programs recently proposed by the Bush Administration (and adopted by the House Budget Committee) will result in 450,000 fewer low-income pregnant women, infants, and young children served by WIC in 2009 than would otherwise be served.160

California Food Policy Advocates. Child Nutrition reauthorization 2003. Available from the California Food Policy Advocates website, http://www.cfpa.net

Personal communication, March 30, 2004, L. Hicks, School Nutrition Coordinator, California Food Policy Advocates.
d e

Ibid

Personal communication, May 20, 2004, C. Brown, Special Assistant to the Director, Nutrition Services Division, California Department of Education.

44

WIC participation in California is high, relative to other food assistance programs (70% to 80% of eligible families participate), but because WIC is a time-limited supplemental benefit targeted to a narrowly defined population, there is a need for continuous outreach. WIC could serve more low-income nutritionally at-risk pregnant women, infants, and young children by increasing supplemental state funding for WIC. Since 1985, numerous legislative attempts to supplement Californias federal WIC monies have failed. In addition, Californias WIC Program has long requested, but not yet received, federal permission to modify its food package to include fresh fruits and vegetables and culturally diverse foods.

It is no surprise that concerns are raised about uncoordinated goals and operations, complicated eligibility and application processes, fragmented services, numerous funding streams, and inconsistent public education messages.162 Experts at the federal, state, and local levels advocate for a statewide policy and plan to govern, prioritize, coordinate, and fund nutrition, food assistance, and physical activity programs. Such a policy could be developed using the framework recommended in Guidelines for Comprehensive Programs to Promote Healthy Eating and Physical Activity, formulated by the Nutrition and Physical Activity Work Group with assistance from the Division of Nutrition and Physical Activity through the Centers for Disease Control and Prevention (CDC-DNPA).163 Other proposals under discussion to more effectively coordinate state nutrition and physical activity programs and messages include:164,165 Establishing the State of California as a model employer of worksite nutrition and physical activity practices; Forming a team to provide centralized leadership, foster work across departments, maximize resources, and decrease duplication; Ensuring that programs address nutrition and physical activity issues with consistent public messages; Designing and funding surveys with adequate sample sizes to ensure that valid and reliable conclusions can be made about Californias ethnic populations; Supporting and developing the capacity of local health departments and nonprofit organizations; and Increasing partnerships with businesses, foundations, nonprofit and voluntary organizations.

UNTAPPED FEDERAL RESOURCES

California has yet to take full advantage of federal dollars available for nutrition and food assistance programs, including direct funds and those requiring a state match. Not only would there be an increase in funds for services, but additional economic benefits as well. For example, USDA calculates that for every food stamp dollar spent, an additional $1.84 is generated in local economic activity. According to one estimate, if California had increased participation in the Food Stamp Program in 2001-2003 at the national average rate of 22.5%, instead of staying virtually flat during the same time period, the state would have received over $356 million in federal benefits for needy Californians. The state would have also experienced an additional $655 million of economic impact when that money was spent for food.161

PROGRAM COORDINATION
Responsibility for Californias nutrition and food assistance programs is distributed among many state agencies, sometimes making program coordination more difficult. The states considerable reliance on federal funding streams contributes to the lack of coordination of nutrition and food assistance programs. The state administers numerous federal programs that often have strict requirements for target populations, client eligibility, and service array. Typically, these programs offer little or no funding for coordination with other programs. Moreover, the large federally supported programs focus almost exclusively on low-income populations and do not allow outreach or service to the large middle-income populations, even though nutrition-related chronic diseases are both prevalent and costly in this large segment of Californias population. By relying so extensively on federal funding to support nutrition and food assistance, the state is bound by the rules, regulations, and funding streams of the federal programs.

CONCLUSION
Leaders in California, as in states throughout the country, are struggling with how to most effectively address the issues of nutrition, food insecurity, overweight, obesity, and physical inactivity and their combined impacts on individual and community health. The purpose of Understanding Nutrition: A Primer on Programs and Policies in California is to assist policymakers, advocates, program managers, and others to better understand these complex issues and to inform dialogue about systemic changes and program improvements that might better serve all Californians.

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ENDNOTES
1

U.S. Department of Health and Human Services. (2001). The Surgeon General's call to action to prevent and decrease overweight and obesity. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General. Available from the Office of the Surgeon Generals website, http://www.surgeongeneral.gov/library

California Department of Education. (2003, November). 2003 California physical fitness testing: Report to the Governor and the Legislature. Retrieved May 25, 2004, from http://www.cde.ca.gov/ta/tg/pf/documents/govreport2003.pdf Sugerman, S., Foerster, S. B., et al. (2003, November 16). Using the 2000 California Teen Eating, Exercise and Nutrition Survey (CalTEENS) to identify indicators of high-risk behavior related to overweight. Presented at the 131st annual meeting of the American Public Health Association, San Francisco, CA.
19 18

17

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2000, November). Healthy People 2010: Understanding and improving health (2nd ed.). Washington, DC: U.S. Government Printing Office. Available from the Healthy People 2010 website, http://www.healthypeople.gov/
3 4

2000 California Teen Eating, Exercise and Nutrition Survey (CalTEENS). (2004, Spring). [Data tables]. Sacramento, CA: California Department of Health Services, Cancer Prevention and Nutrition Section.
20

Goode, E. (2003, July 22). The gorge yourself environment. New York Times, p. F1.

Williamson, D. (2003, January 21). UNC study confirms that food portion sizes increased in U.S. over two decades. Chapel Hill, NC: University of North Carolina News Services. Retrieved April 14, 2004, from http://www.eurekalert.org/ pub_releases/2003-01/uonc-usc011603.php Samuels and Associates. (2000, February). 2000 California high school fast food survey: Findings and recommendations. Sacramento, CA: Public Health Institute. Retrieved May 17, 2004, from http://www.phi.org/pdf-library/ fastfoodsurvey2000.pdf
6 California Department of Health Services. (2001, May). A special report on policy implications of the 1999 California Childrens Healthy Eating and Exercise Practices Survey (CalCHEEPS). (Special report to The California Endowment). Retrieved July 22, 2003, from http://www.dhs.ca.gov/cpns/research/images/ calcheeps050701.pdf 7 5

Andersen, S. A. (Ed.). (1990, November). Core indicators of nutritional state for difficult to sample populations. The Journal of Nutrition, 120(11), 1557S1600S.
21 Hess, D., & Weill, J. (2003, February). State of the states: A profile of food and nutrition programs across the nation. Available from the Food Research and Action Center website, http://www.frac.org

Sullivan, A. F., & Choi, E. (2002, August). Hunger and food insecurity in the fifty states: 19982000. Brandeis University, Heller School for Social Policy and Management, Center on Hunger and Poverty. Retrieved July 14, 2003, from http://www.centeronhunger.org/pdf/statedata98-00.pdf California Department of Finance. (August 2002). Census 2000 California profile. Retrieved April 27, 2004, from http://www.dof.ca.gov/HTML/ DEMOGRAP/Census2000CA_profile.pdf
24 25 23

22

Brown, K. H., et al. (2002, February). Urban agriculture and community food security in the United States: Farming from the city center to the urban fringe. Community Food Security Coalition. Retrieved July 10, 2003, from http://www.foodsecurity.org/urbanagpaper.pdf Story, M., & French, S. (2004, February 10). Food advertising and marketing directed at children and adolescents in the US. International Journal of Behavioral Nutrition and Physical Activity, 1, 3. Retrieved April 14, 2004, from http://www. ijbnpa.org/content/1/1/3 Saville, T., Woodward-Lopez, G., et al. (2000). Improving childrens academic performance, health and quality of life: A top policy commitment in response to childrens obesity and health crisis in California. [Excerpt]. Retrieved January 20, 2004, from http://nature.berkeley.edu/cwh/PDFs/CewaerPaper_Research.pdf U.S. Department of Health and Human Services, National Center for Health Statistics. Prevalence of overweight and obesity among adults: United States, 19992000. [Data file]. Available from the National Center for Health Statistics website, http://www.cdc.gov/nchs/products/pubs/pubd/hestats/obese/obse99.htm U.S. Department of Health and Human Services, National Center for Health Statistics. Prevalence of overweight among children and adolescents: United States, 19992000. [Data file]. Available from the National Center for Health Statistics website, http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overwght99.htm
12 11 10 9 8

Sullivan, A.F., & Choi, E. (2002, August).

Harrison, G. G., et al. (2002, November 11). Over 2.2 million low-income California adults are food insecure: 658,000 suffer hunger. Los Angeles, CA: University of California, Los Angeles, Center for Health Policy Research.
26

California Womens Health Survey dataset documentation and technical report. (2001, March). Sacramento, CA: California Department of Health Services, Cancer Surveillance Section.
27

2000 California Teen Eating, Exercise and Nutrition Survey (CalTEENS). (2004, Spring).
28

Kasper, J., et al. (2000). Hunger in legal immigrants in California, Texas, and Illinois. American Journal of Public Health, 90(10), 16291633.
29 30

Harrison, G. G., et al. (2002, November 11).

Fisher, G. M. (1997, Winter). The development and history of the U.S. poverty thresholds a brief overview. Newsletter of the Government Statistics Section and the Social Statistics Section of the American Statistical Association. Retrieved December 3, 2003, from http://aspe.hhs.gov/poverty/papers/hptgssiv.htm Nord, M., et al. (2002, October). Household food security in the United States, 2001. United States Department of Agriculture, Economic Research Service, Food and Rural Economics Division. (Food Assistance and Nutrition Research Report No. 29). Retrieved July 9, 2003, from http://www.ers.usda.gov/ publications/fanrr29/fanrr29.pdf
32 33 31

Field Research Corporation. (2004). A survey of Californians about the problem of childhood obesity: Conducted for The California Endowment. Retrieved April 16, 2004, from http://www.calendow.org/news/NewsReleases/ 2004/ special/childobesity03031043/ChildObesityCOMPLETEReport3-04.pdf

Harrison, G. G., et al. (2002, November 11).

Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention & Health Promotion, Behavioral Risk Factor Surveillance System. Trends data. Available from the Behavioral Risk Factor Surveillance System, Trends Data website, http://apps.nccd.cdc.gov/brfss/Trends/TrendData.asp
14 15

13

U.S. Department of Health and Human Services. (1988). The Surgeon Generals report on nutrition and health. (Publication No. 88-50210). Washington, DC: U.S. Department of Health and Human Services, Public Health Service.
34

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2000, November). Oppen, M., Sugerman, S., & Foerster, S. B. (2002). Fruit and vegetable consumption in California adults: Ten-year highlights from the California Dietary Practices Surveys 19891999. Retrieved August 5, 2003, from http://www.phi.org/ pdf-library/fruit_survey1102.pdf
35

Ibid. California Department of Health Services. (2001, May).

16 Samuels and Associates. (2002, December). An epidemic: Overweight and unfit children in California Assembly districts. Davis, CA: California Center for Public Health Advocacy. Retrieved May 18, 2004, from http://www. publichealthadvocacy.org/policy_briefs/study_documents/Full_Report1.pdf

46

36 Public Health Institute. (2000). 1999 California Childrens Healthy Eating and Exercise Practices Survey: Fruits and vegetables, a long way to go. (Special Report to the American Cancer Society). Retrieved July 22, 2003, from www.phi.org/pdf-library/CalCHEEPSsurvey.pdf 37

61 62

U.S. Department of Health and Human Services. (2001).

Brown, J. L. (2002, June). The consequences of hunger and food insecurity for children: Evidence from recent scientific studies. Waltham, MA: Brandeis University, Center on Hunger and Poverty.

Revised CalTEENS 1998 data tables, spring 2004. Personal communication, March 3, 2004, S. Sugerman, Research Scientist, Survey Research Group, California Department of Health Services.

63

Brown, J. L., & Pollitt, E. (1996, February). Malnutrition, poverty and intellectual development. Scientific American, 274, 3843.

38

2000 California Teen Eating, Exercise and Nutrition Survey (CalTEENS). (2004, Spring).
39

Center on Hunger, Poverty and Nutrition Policy. (1998). Statement on the link between nutrition and cognitive development in children. Medford, MA: Tufts University.
65

64

U.S. Department of Health and Human Services. (1996). Physical activity and health: A report of the Surgeon General. (NTIS No. AD-A329 047/5INT). Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion.

Dietz, W. H. (1998, February). Childhood weight affects adult morbidity and mortality. Journal of Nutrition, 128 (2 Supp), 411414.

40

Macera, C. A., et al. (2003, August 15). Prevalence of physical activity, including lifestyle activities among adults United States, 20002001. Morbidity and Mortality Weekly Report, 52(32), 764769. Retrieved November 2, 2003, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5232a2.htm

U.S. Department of Agriculture, Food and Nutrition Service. (2003, April). The Emergency Food Assistance Program. [Food Distribution Fact Sheet]. Retrieved October 10, 2003, from http://www.fns.usda.gov/fdd/programs/tefap/pfs-tefap.pdf
67

66

U.S. Department of Agriculture, Economic Research Service. (2003, August 18). Briefing room: Food Stamp Program. Retrieved September 22, 2003, from http:// www.ers.usda.gov/Briefing/FoodStamps/
68 69

41

2000 California Teen Eating, Exercise and Nutrition Survey (CalTEENS). (2004, Spring).
42

Hess, D., & Weill, J. (2003, February).

Centers for Disease Control and Prevention. (2001). Physical activity and good nutrition: Essential elements to prevent chronic diseases and obesity. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Ibid.

Personal communication, August 23, 2004, M. Papin, Manager, Policy Development Unit, Food Stamp Branch, California Department of Social Services. U.S. Department of Agriculture, Food and Nutrition Service. (2004, March 5). Food Stamp Program: Frequently asked questions. Retrieved April 12, 2004, from http://www.fns.usda.gov/fsp/faqs.htm#8 California Department of Social Services. Food Stamps characteristics survey, Federal Fiscal Year 2001. California Department of Social Services, Research and Development Division, CalWORKs and Food Stamps Data Systems Design Task Force. Retrieved April 24, 2004, from http://www.dss.cahwnet.gov/research/ FoodStamp-_430.htm
72 73 74 71 70

43 44

Prevention Institute. Improving the nutrition and physical activity environment in California. Retrieved December 5, 2003, from http://www.preventioninstitute.org/ pdf/Nutrition_PA.pdf
45 46 47

Ibid. Saville, T., Woodward-Lopez, G., et al. (2000).

Ibid. Ibid.

Woodward, E. H. (2000). Media in the home 2000: The fifth annual survey of parents and children. Retrieved December 19, 2003, from http://www. annenbergpublicpolicycenter.org/05_media_developing_child/mediasurvey/ survey7.pdf
48 49 50

California Food Policy Advocates. (1998). California food stamp facts. Retrieved April 1, 2004, from http://www.cfpa.net/foodstamps/Food%20FSBackground.htm Hess, D., & Weill, J. (2003, February).

75 76

California Department of Education. (2003, November). California Department of Health Services. (2001, May).

California WIC Association. (2004, April 16). WIC facts & figures. Retrieved April 17, 2004, from http://www.calwic.org/facts.htm
77

2000 California Teen Eating, Exercise and Nutrition Survey (CalTEENS). (2004, Spring).
51

Personal communication re: SPARK and CATCH studies, February, 2000, J. F. Sallis, Ph.D., Professor of Psychology, San Diego State University. As cited in Saville, T., Woodward-Lopez, G., et al. (2000, December).

Whaley, S., & True, L. (2000). California WIC and Proposition 10: Made for each other. (Halfon, N., et al., Eds.). Los Angeles, CA: University of California, Los Angeles, Center for Healthier Children, Families and Communities. Ibid. California WIC Association. (2004, April 16).

78 79 80

52

Posnick-Goodwin, S. (2002, November). Fitness boosts brainpower. California Educator, 7(3). Retrieved January 22, 2004, from http://www.cta. org/ CaliforniaEducator/v7i3/feature_1.htm
53

Boyles, S. (2001, July 2). Whatever happened to gym class? WebMD Health. Retrieved January 22, 2004, from http://my.webmd.com/content/article/12/ 1676_53042.htm
54 55

U.S. House of Representatives, Committee on Ways and Means. (2003). Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). 2003 Green Book. Retrieved March 2, 2004, from http:// waysandmeans.house.gov/media/pdf/greenbook2003/WIC.pdf
81

Personal communication, September 19, 2003, L. True, Executive Director, California WIC Association.

Posnick-Goodwin, S. (2002, November). Ibid.

82 Personal communication, February 18, 2004, L. True, Executive Director, California WIC Association. 83 U.S. Department of Agriculture, Food and Nutrition Service. (2003, September 1). WIC Farmers Market Nutrition Program: Grant levels by state. Retrieved January 1, 2003, from http://www.fns.usda.gov/wic/FMNP/FMNP grantlevels.htm 84 California WIC Association. (2001, April). WIC Farmers Market Nutrition Program. Retrieved February 25, 2004, from http://www.calwic.org/ farmers_market.htm

56 Elliott, E., & Sanders, S. (2002, February 3). Keep children moving: Promoting physical activity throughout the curriculum. Retrieved January 22, 2004, from http://www.pecentral.org/professional/articlesdirectlyrelatedtope.html 57 58

Boyles, S. (2001, July 2).

Mokdad, A. H., et al. (2004, March 10). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 291, 12381245.

59

Estimated from data in Allison, D. B., et al., 1999, Annual deaths attributable to obesity in the United States, Journal of the American Medical Association, 282, 15301538. Gregory, S. (Ed.). (2002). Guidelines for comprehensive programs to promote healthy eating and physical activity. Nutrition and Physical Activity Work Group. Retrieved July 9, 2003, from http://www.astphnd.org/programs/guidelines/htm
60

California Department of Education. Fingertip facts on education in California. Fact Book 2003. Retrieved May 25, 2004, from http://www.cde.ca.gov/re/pn/fb/ yr03facts.asp

85

47

California Department of Education. (2002, December). FY 200102 county profile for California school nutrition programs. Retrieved May 25, 2004, from http://www.cde.ca.gov/ds/sh/sn/documents/coproschool0102.pdf
87 88

86

108 Nelson, T., et al. (2002). Weaving the food web: Community food security in California. Available from the Community Food Security Coalition website, http://www.foodsecurity.org

Hess, D., & Weill, J. (2003, February).

U.S. Department of Agriculture, Food and Nutrition Service. FNS Online. Retrieved February 16, 2004, from http://www.fns.usda.gov/cnd/Care/CACFP/ snacks.htm Food Research and Action Center. The child nutrition programs. Retrieved March 20, 2004, from http://www.frac.org/pdf/rates.PDF
90 89

Bolen, E., & Hecht, K. (2003, January). Neighborhood groceries: New access to healthy food in low-income communities. Available from the California Food Policy Advocates website, from http://www.cfpa.net Shaffer, A. (2002). The persistence of L.A.s grocery store gap: The need for a new food policy and approach to market development. Occidental College, Urban and Environmental Policy Institute, Center for Food and Justice. Retrieved June 20, 2004, from http://departments.oxy.edu/uepi/cfj/resources/ Supermarket%20Report%20November%202002.pdf Transportation for Healthy Communities Collaborative. (2002, October). Roadblocks to health: Transportation barriers to healthy communities. Retrieved December 26, 2003, from http://www.transcoalition.org/reports/rb/roadblocks.pdf
112 113 114 111 110

109

California Department of Education. (2004, April 19). Rates 2003-2004: Child Nutrition Programs' 2003-2004 reimbursement rates. Retrieved June 1, 2004, from http://www.cde.ca.gov/ls/nu/rs/rates0304.asp Hess, D., & Weill, J. (2003, February).

91 92

U.S. Department of Agriculture, Food and Nutrition Service. (2003, August). School Meals Programs: Special Milk Program. Retrieved on May 19, 2004, from http://www.fns.usda.gov/cnd/Milk/About Milk/about.htm U.S. Department of Agriculture, Food and Nutrition Service. (2003, August 28). Special Milk Program: Total half-pints served. Retrieved on September 30, 2003, from http://www.fns.usda.gov/pd/smhpfy.htm California Child Care Resource & Referral Network. (2001). The 2001 California Child Care Portfolio. [Excerpt]. Retrieved February 6, 2004, from http://www.rrnetwork.org/rrnet/uploads/1012951925.pdf
95 96 94 93

Bolen, E., & Hecht, K. (2003, January). Nelson, T., et al. (2002).

Healthy farms, healthy kids: The California Farm to School Program. Available from the California Farm to School website, http://www.farmtoschool.org
115

Appelson, G. (2003, September 4). US judge throws out obesity suit against McDonalds. Reuters. Retrieved March 7, 2004, from http://www.licenseenews.com/ news/news216.html

116

Hess, D., & Weill, J. (2003, February).

Carpenter, D. (2004, March 2). McDonalds menu to go on diet in 2005. Associated Press. Retrieved April 9, 2004, from http://apnews.myway.com/ article/20040303/D812LI680.html
117

California Department of Education, Nutrition Services Division. Adult day care center component [of the Child and Adult Care Food Program (CACFP)]. Retrieved May 25, 2004, from http://www.cde.ca.gov/ls/nu/cc/adc.asp Unless otherwise indicated, the data in this section was provided and reviewed April 2, 2004, by L. Hodge, R.D., California Department of Aging.
98 97

Harkin pushes menu education and labeling initiative to help curb obesity. (2003, November 5). [Press release]. Retrieved March 7, 2004, from http:// harkin.senate.gov/press/print-release.cfm?id=214633
118

Personal communication re: 2000 Census, April 22, 2004, D. Kuczynski, Demographic Research Unit, California Department of Finance.

Fox, M. (2004, March 12). FDA asks for clearer labels of food, menus. Reuters Health Information. Retrieved May 14, 2004, from http://www. ucsfhealth.org/childrens/health_library/reuters/2004/03/ 20040312elin001.html
119

99

Steinman, E. (2003, August). Preventing hunger among elderly Californians. Available from the California Food Policy Advocates website, http://www.cfpa.net U.S. Department of Agriculture. (2003, March). Senior Farmers Market Nutrition Program. Retrieved February 6, 2004, from http://www.fns.usda.gov/wic/ SeniorFMNP/SFMNPFY03.htm California Health and Human Services Agency, California Department of Aging. (2003, May 8). California Department of Aging (CDA) poverty and low income requirements, U.S. Department of Health and Human Services (DHHS) annual Poverty Guidelines update, and updated income eligibility criteria for Title V, Brown Bag, Senior Companion, and Foster Grandparent Programs. Program Memo No. PM 03-09 (P). Retrieved April 15, 2004, from http://www. aging.state.ca.us/PM/pm03-09/PM03-09.pdf California Department of Social Services. (2003, July 23). Emergency Food Assistance Program. Retrieved on October 3, 2003, from http://www.dss.cahwnet. gov/cdssweb/EmergencyF_195.htm Personal communication, October 10, 2003, D. Allen, Program Manager, Commodity Supplemental Food Program, California Department of Social Services.
104 103 102 101 100

Davis, J. L. (2003, November 5). Nutrition info on menus: Coming soon? Retrieved November 6, 2003, from http://www.my.webmd.com/content/ article/76/90160.htm
120 U.S. Food and Drug Administration. (2004, March 12). Calories count: Report of the Working Group on Obesity. Retrieved March 24, 2004, from http://www.cfsan.fda.gov/~dms/owg-toc.html

Gallo, A. E. (1999). Food advertising in the United States. In E. Frazao (Ed.), Americas eating habits: Changes and consequences. (pp. 173180). Washington, D.C.: Economic Research Service, U.S. Department of Agriculture. Retrieved January 2, 2004, from www.ers.usda.gov/publications/aib750/aib750i.pdf
122

121

Center for Science in the Public Interest. (2003, November). Pestering parents: How food companies market obesity to children: Part two. Retrieved December 31, 2003, from www.cspinet.org/new/pdf/pestering_parents_final_part_2.pdf

Gamble, M., & Cotugna, N. (1999). A quarter century of TV food advertising targeted at children. American Journal of Health Behavior, 23, 261267. Byrd-Bredbenner, C., & Grasso, D. (2000). What is television trying to make children swallow? Content analysis of the nutrition information in prime-time advertisements. Journal of Nutrition Education, 32, 187195.
125 124

123

U.S. Department of Agriculture, Food and Nutrition Service. (2003, August 28). Food Distribution Program on Indian Reservations: Annual participation. Retrieved on October 5, 2003, from http://www.fns.usda.gov/pd/irpart.htm
105

Kotz, K., & Story, M. (1994). Food advertisements during childrens Saturday morning television programming: Are they consistent with dietary recommendations? Journal of the American Dietetic Association, 94, 12961300.
126

U.S. Department of Agriculture, Food and Nutrition Service. (2004, April 12). Food Distribution Program on Indian Reservations. Retrieved April 17, 2004, from http://www.fns.usda.gov/fdd/contacts/fdpir-contacts.PDF
106

U.S. Department of Agriculture, Food and Nutrition Service. (2003, March). Food Distribution Program on Indian Reservations. [Fact sheet]. Retrieved October 5, 2003, from http://www.fns.usda.gov/fdd/programs/fdpir/pfs-fdpir.pdf
107

California Adolescent Nutrition and Fitness Program, & California Pan-Ethnic Health Network. (2003, August). Communities of color issue briefing paper: Addressing the obesity epidemic public policies for healthy eating and physical activity environments. Retrieved January 30, 2004, from http://www.canfit.org/ CANFit-CPEHNbriefFINALformat.pdf
127 American School Food Service Association. (2004, January 21). APHA urges for schools free of food advertising. Retrieved April 21, 2004, from http://www.asfsa.org/newsroom/sfsnews/aphaadvres.asp

Center for Civic Partnerships. (2002). Fresh ideas for community nutrition and physical activity. Sacramento, CA: Public Health Institute.

48

U.S. Department of Agriculture, Food and Nutrition Service. (2001, January 12). Foods sold in competition with USDA School Meal Programs. Retrieved April 28, 2004, from http://www.fns.usda.gov/cnd/Lunch/CompetitiveFoods/ report_congress.htm#top
129 130

128

151

Center for Civic Partnerships. (2002). Fresh ideas for community nutrition and physical activity. Sacramento, CA: Public Health Institute.

Samuels and Associates. (2000, February).

Personal communication, April 12, 2004, P. Agron, California Project LEAN, & N. Gelbard, Chief, California Obesity Prevention Initiative, California Department of Health Services. Schirm, A. L., & Castner, L. A. (2004, February). Reaching those in need: State food stamp participation rates in 2001. United States Department of Agriculture, Food and Nutrition Service. Retrieved March 21, 2004, from http://www. fns.usda.gov/oane/MENU/Published/FSP/FILES/Participation/Reaching2001.pdf
154 153

152

California Department of Health Services, Research and Evaluation Unit. (2002, August). Special report to the American Cancer Society: Are Californians meeting ACS nutrition guidelines for cancer prevention? Findings from three statewide surveys of children, teens, and adults. (Revised). Retrieved May 20, 2004, from http://www.dhs.ca.gov/ps/cdic/cpns/research/images/ ACS%20Rev%20AUG%202002%20-%207%2025%2002.pdf
131

2000 California Teen Eating, Exercise and Nutrition Survey (CalTEENS). (2004, Spring).
132

Llobrera, J. (2003, November 12). Food stamp caseloads are rising. (Revised). Center on Budget and Policy Priorities. Retrieved March 21, 2004, from http:// www.cbpp.org/1-15-02fa.pdf

Personal communication, March 25, 2004, H. Goldstein, Executive Director, California Center for Public Health Advocacy. Catalog of Federal Domestic Assistance. Team Nutrition Grants. Retrieved March 6, 2004, from http://12.46.245.173/pls/portal30/SYSTEM. PROGRAM_TEXT_RPT.SHOW?p_arg_names=prog_nbr&p_arg_values=10.574

133

California State Auditor. (2003, January 2). Statewide fingerprint imaging system: The State must weigh factors other than need and cost-effectiveness when determining future funding for the system. (Bureau of State Audits Report No. 2001-015). Retrieved April 2, 2004, from http://www.bsa.ca.gov/bsa/reports/2003.html California Food Policy Advocates. (2002, January 18). School Breakfast Program facts. Available from the California Food Policy Advocates website, http://www.cfpa.net
157 158 156

155

134

Personal communication, April 20, 2004, S. B. Foerster, Chief, Cancer Prevention and Nutrition Section, California Department of Health Services.

California Department of Health Services. (2001, May).

135

2000 California Teen Eating, Exercise and Nutrition Survey (CalTEENS). (2004, Spring).
136 137

Hess, D., & Weill, J. (2004, April). State of the states: 2004. Available from the Food Research and Action Center website, http://www.frac.org

California Department of Education. (2003, November).

Personal communication, April 12, 2004, P. Agron, California Project LEAN, & N. Gelbard, Chief, California Obesity Prevention Initiative, California Department of Health Services. Personal communication, March 25, 2004, H. Goldstein, Executive Director, California Center for Public Health Advocacy. Ibid. Ibid.

159 Harrington, S. (2002, March). Breakfast basics: A guide to feeding hungry minds in California through the School Breakfast Program. Available from the California Food Policy Advocates website, http://www.cfpa.net

138

Center on Budget and Policy Priorities. (2004, March 5). Broad cuts in domestic programs after 2005 under administration budget. [Fact Sheet]. (Revised). Retrieved March 24, 2004, from http://www.cbpp.org/2-27-04bud-fact.htm
161 California Hunger Action Coalition. (2003, May). Last in line: Californias Food Stamp Program is nations worst at responding to rising unemployment: Hundredsof millions of dollars lost. Retrieved October 30, 2003, from http://www. hungeraction.net/media/pdf_files/report_050803.pdf 162 Memo from Strategic Alliance forwarded to California Health and Human Services Agency Secretary Kim Belsh, February 2, 2004. 163 Gregory, S. (Ed.). (2002). Guidelines for comprehensive programs to promote healthy eating and physical activity. Nutrition and Physical Activity Work Group. Retrieved March 8, 2004, from http://www.astphnd.org/ 164 165

160

139 140 141

Vardon, S. G. (2002, November 15). Teaching gym class: Fitness, not competition, is focus in new P.E. Orange County Register. Available from the Orange County Register website, http://www.ocregister.com

142

New PE emphasizes lifetime fitness goals. (2002, November). California Educator, 7(3). Retrieved January 4, 2004, from http://www.cta.org/ CaliforniaEducator/v7i3/feature_2.htm

Backman, D. R., Carman, J. S., & Aldana, S. G. (2004, January). Fruits and vegetables and physical activity at the worksite: Business leaders and working women speak out on access and environment. Retrieved April 29, 2004, from http://www.phi.org/pdf-library/dhs-worksite.pdf
144 145

143

Ibid.

Memo from Strategic Alliance forwarded to California Health and Human Services Agency Secretary Kim Belsh, February 2, 2004.

Ibid.

Pollard, T. (2003, September/October). Policy prescriptions for healthier communities. American Journal of Health Promotion, 18(1), 109113.

146

McKee, B. (2003, September 4). As suburbs grow, so do waistlines. The New York Times, p. F1. Retrieved January 21, 2004, from http://www.camdennewjersey.org/suburban_waistlines_grow.htm
147

Pucher, J., & Dijkstra, L. (2003). Promoting safe walking and cycling to improve public health: Lessons from the Netherlands and Germany. American Journal of Public Health, 93(9), 15091516.
148

McCann, B. A., & Ewing, R. (2003, September). Measuring the health effects of sprawl: A national analysis of physical activity, obesity and chronic disease. Smart Growth America and Surface Transportation Policy Project. Retrieved April 16, 2004, from http://www.smartgrowthamerica.org/report/HealthSprawl8.03.pdf Bolen, E., & Hecht, K. (2003, January).

149 150

Ewing, R., et al. (2003, September/October). Relationship between urban sprawl and physical activity, obesity, and morbidity. American Journal of Health Promotion, 18(1), 4757. Retrieved January 22, 2004, from http://www.smartgrowth.umd.edu/pdf/JournalArticle.pdf

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ABOUT CCRWF
The California Center for Research on Women and Families (CCRWF) is a division of the Public Health Institute. In addition to sponsoring the Primer Project, CCRWF is home to the California Working Families Policy Summit, the CalWORKs/Child Welfare Partnership Project, and the Outcomes Project. The mission of CCRWF is to provide information, facilitation, analysis, and policy options to help leaders improve the lives of women and families in our state and nation. To accomplish our mission, professionals at CCRWF typically work collaboratively with individuals from a wide variety of fields and backgrounds. Research, development of educational materials, facilitation, training, and convenings hosted by CCRWF often involve policymakers, researchers, managers of government-funded programs, nonprofit leaders, journalists, consumers, and community leaders. In addition to our commitment to collaboration and broad-based information gathering, professionals at CCRWF also have a strong commitment to translating research into action and recommendations into policy.

ABOUT

THE

AUTHORS

Diane F. Reed, M.P.H., has over twenty years of experience providing program planning and development, policy analysis, research, and grant-writing services to public and private agencies and community-based organizations in California. She has conducted research and analysis, published articles, and prepared case studies, comprehensive needs assessments, and reports in the areas of child welfare, domestic violence, children of incarcerated parents, alcohol, tobacco and other drugs, HIV/AIDS, perinatal health, early childhood education, and community-based agencies. Ms. Reed received a Masters in Public Health from UC Berkeley in Policy and Planning. Kate Karpilow, Ph.D., is the Executive Director of the California Center for Research on Women and Families (CCRWF). She has managed policy projects and conducted research in the areas of child welfare, welfare reform, health care, child care, and working families. She is the founder and director of the California Working Families Policy Summit, which is based at CCRWF. Ms. Karpilow has worked in a variety of positions in local and state government and as a consultant to philanthropic foundations. She received her Ph.D. from Harvard University in Psychology and Social Relations.

SUPPORT

FOR THIS

PRIMER

Funding for the Primer was provided by the U.S. Department of Agriculture Food Stamp Program, an equal opportunity employer and provider, through the California Nutrition Network for Healthy, Active Families. For information about the California Food Stamp Program, please go to http://www.dss.cahwnet.gov/ foodstamps/, or call 1-800-952-5253.

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